Here's an example of a scenario working with a provider during a patient encounter: Enjoy!
Dr. John: Hello. How are you today? What brings you to the ER today?
Patient (pt.): I've had this horrible cough, fever, nasal congestion, pain in my face, and runny nose. I'm miserable.
: 36 y/o F c/o cough, fever, nasal congestion, facial pain, and rhinorrhea. (age and sex on the triage note)
Dr. John: How long has this been happening?
Pt.: About a week or so
: pt. c/o cough, fever, nasal congestion, facial pain, and rhinorrhea x 1 week.
Dr. John: Any bad headaches, vomiting, nausea, chest pain, abdominal pain, difficulty breathing?
Pt.: No (to each)
: Denies HA, V/N, Chest pain, abd. pain, dyspnea.
Dr. John: Anything make it better or worse?
Pt.: Oh Doc, I've tried everything... Nothing works.
: No modifying factors leading to improvement of sx.
Dr. John: Have you taken anything recently?
Pt.: Just some Motrin before coming.
: Pt. took Motrin prior to arrival.
Dr. John: Are you allergic to any medication?
Dr. John: Any prior medical history (e.g. asthma, COPD), surgical history, or family history?
Pt.: I had my tonsils removed when I was young.
: [under surgical hx] tonsillectomy
Dr. John: O.k. now I'm just going to look you over and you make hear me babbling about what I find, but that's for [your name] to help me document. ...this is where you'd write down the physical exam (exactly what they tell you-usually the positives and significant negatives), an end medical management piece (which they also tell you):
Pt. has mild tenderness to the frontal sinuses upon palpation, nasal congestion, mildly erythematous turbinates, and clear discharge from bilateral nares. Oropharynx exam has post nasal drainage, no uvular deviation or oral petechaie. Bilateral TM clear and normal. Anterior lymphadenopathy. Lungs clear to auscultation, no wheezing, or consolidation. All vitals stable.
No indication for XR/CT scan, labs.
Final dx: Acute Sinusitis
Pt. to be discharged with script for antibiotic (Dr. will do this himself).
If sx. worsen or does not improve, return to E.R. or see PCP. Follow up with PCP in 2-3 days.
Scribe signs and makes sure the Dr. Signs. IF the provider doesn't sign the chart or is missing something, it will be checked by someone in the HIM dept. and sent back to the provider. Sometimes when a resident is charting and they forget to sign or forget the entire physical exam/medical management, the chart is sent to the attending and they have to redo the entire chart (whether they remember the patient or not. they probably didn't take care of him/her either..). Any order are separately done by the provider (depending on the policy, you can note that or not). Consults can be charted with the medical management (e.g. at 1405, Spoke with Dr. Name in Ortho services. Dr. Name reviewed the XR and saw pt. in the ER at 1420. Dr. Name comfortable with discharging pt. and following up with him on an outpatient basis".