Services
Our scribes provide all or part of the following:
Subjective
Pertains to any information that the patient and/or family states.
- The patient's Chief Complaint, or reason for their visit to the ED
- History of Present Illness (HPI), which describes why the patient is in the department and lists any pertinent positive and negative ROS
- Location
- Quality
- Severity
- Duration
- Timing
- Context
- Modifying Factors
- Associated Signs and Symptoms
- Review of Systems (ROS), which identifies any recent symptoms the patient may have either related or unrelated to the Chief Complaint. The 12 Systems listed in the ROS are:
- Constitutional
- Ears, Nose, Mouth, Throat
- Eyes
- Respiratory
- Cardiovascular
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Skin
- Neurologic
- Hematologic
- Psychiatric
- Past Medical History (PMHx) including any injuries, illnesses, hospitalizations, surgeries, routine medications and/or drug allergies
- Social History (SHx), which clarifies the patient's living situation, marital status, or employment status, or identifies any behavioral risks the patient may have such as tobacco, alcohol, or drug abuse
- Family History (FMHx), which includes any relevant past family medical information
Objective
Contains information obtained through observation and testing and is independent of an individual's interpretation.
- Physical Examination (PEx) - any information elicited through observation, palpation, percussion, and auscultation
- Medical Decision Making (MDM) is itself made up of four sub-sections:
- Orders/MDM, where tests and medications are ordered
- Investigations section, which contains the results of the labs, X-Rays, CT-Scans, etc. that the physician orders
- Procedures/MDM Continued/Consultations section, which records procedure notes (sutures, intubations, lumbar punctures, etc.), further lab results, and any consultations with other physicians to coordinate patient care
