Level IV: General Comments

 Urgent Urgent Tx of condition of condition 

 Multiple diagnostic studies 

 Special studies alone (CT, MRI,US) 

 ED Interventions: 

 Nebs 21 

 Parenteral Parenteral medications medications 

 Usually not admitted 

Level V: General Comments 

 Many Admissions Frequently Involve: 

 Prolonged services in ED 

 Special Studies with other tests Special Studies with other tests-(CT/MRI/US) (CT/MRI/US) 

 Multiple reassessments 

 Interpretations of EKG or x Interpretations of EKG or x-rays 

 Old record review 

 Documented conversations

History 

The history portion of a patient The history history portion portion of a patient s patient s’ chart includes some or all of the following elements: 

 Chief complaint (CC) 

 History of present illness resent illness (HPI) 

 Review of systems (ROS) 

 Past, family and/or social history (PFS)

History of Present Illness

 Location-left sided chest pain, upper, lower, left sided chest pain, upper, lower, History of Present Illness posterior 

 Context –while shoveling snow, while while shoveling snow, while cutting a roll, during the football game, scratched by the cat 

 Quality –sharp chest pain, throbbing headache, headache, crampy belly pain 

 Timing – worse at night, daily, constant, worse at night, daily, constant, frequent