Below are two examples of the type of screening notes you will be writing.

Following the examples are

practice scenarios. These practice scenarios are all for screening documentation, so you will not be
documenting the entire chart.
Example #1
Pt: Ive been having stomach pains right here down at the left for the last week. Ive kind of had this
before with diverticulitis but Im not sure if this is really the same, its definitely the same area though.
Yesterday I had some loose poop too and today Ive felt hot and then cold all day long.
Dr: Was there any blood in the stool? Any documented fever? Anything else bothering you today?
Pt: No blood or anything. Just brown and really watery. I dont have a thermometer. Just this pain and
the diarrhea, theres nothing else.
Dr: Quick exam of abd-soft, LLQ TTP, no distention. Plan: Lab eval, pain management, and radiographic
images
Note: 55 year old female with h/o diverticulitis presents to ED with one week of LLQ abd pain and 1 day
of watery, brown diarrhea and subjective fever. Similar location of previous pain with diverticulitis.
Denies hematochezia or melena. PE: Abd is soft and nondistended, +LLQ TTP. Plan: Patient stable. Main
ED bed requested. Laboratory evaluation, pain management, and radiographic images.
Explanation: This note is pretty self-explanatory. Lab eval is for blood work-likely CBC diff, CMP, LFTs,
and UA. Pain management-likely narcotics for pain. Pain meds are also called analgesics. Radiographic
images-pt with h/o diverticulitis, CT A/P with PO to r/o same.
Example #2
Pt: Ive been short of breath since I woke up this morning. Ive never had this before and it scared me.
Dr: Do you have a h/o COPD, asthma, or smoking?
Pt: No I dont have any of that. I also had some chest pain this morning at 4am that woke me up. It went
away when I took my nitro though so I just went back to sleep.
Dr: Tell me more about this chest pain. Where was it? How long did it last? Were there any other
symptoms?
Pt: It was right in the left chest and it lasted about 30 minutes until I took 3 nitros. I was really nauseous
at the time too but I didnt actually get sick.
Dr: Anything else?
Pt: No, thats it.
Dr: Quick exam of CV/Resp-RRR, LCTAB. Plan: Lab eval, medical management, radiographic images,
electrocardiogram
Note: 77 year old male with h/o CAD, MI, and HTN presents to ED with constant SOB since waking
today. Also endorses episode of L upper chest pain and nausea onset suddenly at 4am waking him from
sleep, lasting 30 minutes and resolved with sublingual nitro x3. No chest pain currently. No h/o COPD,
asthma, or smoking. No other complaints noted. PE: RRR. LCTAB. Laboratory evaluation, medical
management, radiographic images, electrocardiogram.
Explanation: We know he has a h/o of CAD because he takes nitro at home. Remember that nitro is a
medication used to tx angina, which is chest pain associated with CAD. Start making these connections!
The MI was part of the pmhx documented in the pts chart. Sublingual nitro means to take under the
tongue, this is the only form of nitro that pts use at home. LCTAB stands for Lungs Clear To Auscultation
Bilaterally. Any chest pain that is relieved with nitro is automatically cardiac related so this pain will
most definitely get sent to Main ED; lab eval-trop, CKMB, CBC diff, CMP; medical management-IVF(IV
fluids) and aspirin; radiographic images-CXR; EKG.
*I recommend you start learning more extensive medical vocabulary than what was taught in training.
Flashcard terms you dont know and start learning them. There will be many throughout these
scenarios. I also recommend that you google a phrase to learn the medical term for it, for example: pain
with sex, you would google medical term for painful sexual intercourse. Ive used this term probably
every day while working clinically at this ED (we see lots of pelvic pains/vaginal complaints!) Google the
term and memorize it! Do this for every phrase that sounds like there could be a medical term for it,
chances are good that theres a term! Ill provide a list at the end of this document of terms Ive used a
lot lately. Please flashcard these and start learning!
Practice Scenarios
Scenario #1
Pt: I was helping a friend move last night and my low back is just killing me today! It hurt some last night
but I took Tylenol and went to sleep. This morning I was so stiff!
Dr: Does it hurt on both sides? Have you had any problems with your urine or bowels? Any numbness or
weakness in the legs?
Pt: Yeah both sides hurt. My bowels and urine have been normal and my legs too, its just the low back.
Dr: Fever? Chills?
Pt: Nope
Dr: Quick back exam- bilat upper and lower lumbar paraspinal muscle TTP. Without deformities, step
offs, or midline bony TTP. NVI* distally, strength and sensation good. Plan: Patient is stable. FT**.
Medical management.
*Neurovascularly intact
**Fast turnaround

Scenario #2
Pt: I just landed from Nigeria two days ago and since then Ive been very tired and exhausted.
Dr: Any other sxs?
Pt: Also I feel like its hard to breath and this morning I had some pain right in the middle upper
stomach, only lasted like 10-15 minutes though and then went away.
Dr: Any exposure to mosquitos or known malaria regions while in Nigeria?
Pt: I dont think so
Dr: Chills? Fever? Nausea? Vomiting? Bleeding of any kind? How long was the flight?
Pt: None of that. The total travel time was 23 hours.
Dr: Exam deferred to discharge provider. Plan: Patient stable. FT. Lab eval, medical management, re-eval
after results and IVF.


Scenario #3
Pt: I was just over at the Hopkins cancer center getting my chemo and I started getting chest pains and I
couldnt catch my breath. My doctor sent me here for some kind of clot.
Dr: What kind of cancer do you have?
Pt: I just got diagnosed with breast cancer last week and today was my first chemo.
Dr: Did you have any other symptoms prior to the episode at chemo? Have you been feeling normal
lately? Do you still have these symptoms?
Pt: Ive been feeling great! Nothing else is going on. I do still have the chest pain under my L breast and I
feel like my breathing is a little hard.
Dr: Exam deferred to main ED provider. Plan: Patient stable. Main ED requested. Lab eval, medical
management, pain management, radiographic images, potential consult.


Scenario #4
Pt: I stubbed my toe last night and my nail is all black and blue and my toe swolled up.
Dr: Any other injuries?
Pt: Nah, just that. I can still move it a little but the toe be hurtin!
Dr: Quick visual exam of L great toe- Subungual hematoma with superficial avulsion of the distal skin to
the L great toe, mild swelling, rest of exam deferred to discharge provider. Plan: Patient stable. FT.
Medical management, pain management, radiographic images, needs procedure.
*look up what a subungual hematoma is and what procedure would be required for this, start learning
associated procedures with different diagnoses.
More Medical Terms
1. Dysmenorrhea- painful menstruation, typically involving abdominal cramps.
2. Dyspareunia- difficult or painful sexual intercourse
3. Menorrhagia- abnormal, heavy bleeding at menstruation
4. Pinna motion tenderness- pain with motion of the pinna of the ear. The pinna is the visible part
of the ear that resides outside of the head (basically the cartilage of the upper ear)
5. Popliteal Pulse- pulse behind the knee. This is checked by some providers in pts with concern
for DVT
6. Postprandial- during or relating to the period after dinner or lunch. Typically related to
gallbladder pain (ex. Onset of postprandial RUQ pain this afternoon)
7. Posttussive emesis- vomiting after an episode of coughing. In patient with this, there is no true
nausea, they typically vomit from coughing too hard
These are the ones Ive use a lot over the last week. I dont want to overwhelm you with tons of
terms, so just start learning these gradually! My general practice throughout my scribe career has
been to learn two new medical terms per day. If you make this your practice, youll have a broad
vocabulary in no time at all!