Envision Quiz 3 (EDC&T),
What is the emergency department course and treatment? - answerA detailed
description of the course of events that happen during a patients visit and the clinicians
medical decision making process and clarifies the clinicians medical decision making
process
What details can the etc and t include? - answer1. Summary of old medical records 2.
medications/treatments given and patient's response 3. re-evaluations, 4. repeat vital
signs, 5. consultations and conversations
What will the physician review prior records for? - answer Previous relevant ed visits,
history of recurrent visits for the same chief complaint, and previous lab or imaging
study results
At minimum what should you record from the past medical records - answerSource of
the info (EDIMS), date, complaint/diagnosis, disposition
Treatments - answermedical care given to a patient for an illness or injury
What should be recorded for medication - answerName, dosage, route of administration
What should be recorded for IV fluids - answerName, total volume, route of
administration, rate (bolus vs an act over time)
What type of info is in a re-evaluation - answerCan be subjective or objective
information. subjective- info from patient. Objective- clinical assessment from physician.
Repeat vitals - answerIf a patient initially presents with abnormal vital signs, a repeat set
must be documented
What must you document about a procedure - answerThe procedures name and title
What to document about a consultation - answerTime the convo happened, clinician's
name, clinician's specialty and any recommendations given
What to document about a convo w family - answerWhy patient is unable to participate,
the subject of the discussion and the outcome.
What to document about counseling - answerTime spent answering the patients
questions
What is the emergency department course and treatment? - answerA detailed
description of the course of events that happen during a patients visit and the clinicians
medical decision making process and clarifies the clinicians medical decision making
process
What details can the etc and t include? - answer1. Summary of old medical records 2.
medications/treatments given and patient's response 3. re-evaluations, 4. repeat vital
signs, 5. consultations and conversations
What will the physician review prior records for? - answer Previous relevant ed visits,
history of recurrent visits for the same chief complaint, and previous lab or imaging
study results
At minimum what should you record from the past medical records - answerSource of
the info (EDIMS), date, complaint/diagnosis, disposition
Treatments - answermedical care given to a patient for an illness or injury
What should be recorded for medication - answerName, dosage, route of administration
What should be recorded for IV fluids - answerName, total volume, route of
administration, rate (bolus vs an act over time)
What type of info is in a re-evaluation - answerCan be subjective or objective
information. subjective- info from patient. Objective- clinical assessment from physician.
Repeat vitals - answerIf a patient initially presents with abnormal vital signs, a repeat set
must be documented
What must you document about a procedure - answerThe procedures name and title
What to document about a consultation - answerTime the convo happened, clinician's
name, clinician's specialty and any recommendations given
What to document about a convo w family - answerWhy patient is unable to participate,
the subject of the discussion and the outcome.
What to document about counseling - answerTime spent answering the patients
questions
