Scribe America Hospitalist Final UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS
History and Physical (H&P) The pertinent information about the patient, including chief complaint, past and
present illnesses, family history, social history, and review of body systems
Contains recap of why patient came in for evaluation and preliminary physician
findings
Assessment and Plan Based on the patient's subjective complaints and objective findings the physician
will create a problem list to discuss the known diagnoses and differential
diagnoses along with any comorbidities, supporting history and treatment plan
Disposition Discharge, Admit, Transfer
Where would has a prior diagnosis of hyperlipidemia go? Medical history
Where would lungs are clear to auscultation go? Physical Exam
Where would had gallbladder removed go? Surgical history
Where would chest xray shows pneumonia go? Results
Where would heart rate is 95 bpm go? Vital Signs
Where would ive had a cough for 3 days go? HPI/ROS
, Past Medical History (PMHx) other significant past illnesses, like high blood pressure, asthma, or diabetes ex.
hypertension puts at risk for heart attach
Layman's term: what patient calls disease
Medical term: what scribe will document
Abbreviation
Laymans High Blood Pressure Hypertension (HTN)
Layman's high cholesterol hyperlipidemia (HLD)
Layman's diabetes Diabetes Mellitus (DM)
"I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Type 2
"I take shots (insulin) for my diabetes" Insulin Dependent Diabetes Mellitus
(IDDM)
Type 1
Layman's Thyroid problem Hypothyroidisim
Layman's Heart Disease Coronary Artery Disease (CAD)
Layman's Heart attack Myocardial Infraction (MI) and CAD
Layman's heart failure Congestive heart failure (CHF)
Layman's irregular heartbeat arrhythmia
Layman's emphysema or chronic bronchitis Chronic Obstructive Pulmonary Disease (COPD)
Layman's Blood clot in lung Pulmonary Embolism (PE)
Layman's reflux Gastroesophageal Reflux Disease (GERD)
Layman's Ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Layman's bladder infection Urinary Tract Infection (UTI)
Layman's Kidney Infection Pyelonephritis
Layman's Kidney Stones Renal Calculi
Layman's "Im on dialysis" Chronic Kidney Disease (CKD) on dialysis
Layman's enlarged prostate Benign Prostatic Hyperplasia (BPH)
ANSWERS
History and Physical (H&P) The pertinent information about the patient, including chief complaint, past and
present illnesses, family history, social history, and review of body systems
Contains recap of why patient came in for evaluation and preliminary physician
findings
Assessment and Plan Based on the patient's subjective complaints and objective findings the physician
will create a problem list to discuss the known diagnoses and differential
diagnoses along with any comorbidities, supporting history and treatment plan
Disposition Discharge, Admit, Transfer
Where would has a prior diagnosis of hyperlipidemia go? Medical history
Where would lungs are clear to auscultation go? Physical Exam
Where would had gallbladder removed go? Surgical history
Where would chest xray shows pneumonia go? Results
Where would heart rate is 95 bpm go? Vital Signs
Where would ive had a cough for 3 days go? HPI/ROS
, Past Medical History (PMHx) other significant past illnesses, like high blood pressure, asthma, or diabetes ex.
hypertension puts at risk for heart attach
Layman's term: what patient calls disease
Medical term: what scribe will document
Abbreviation
Laymans High Blood Pressure Hypertension (HTN)
Layman's high cholesterol hyperlipidemia (HLD)
Layman's diabetes Diabetes Mellitus (DM)
"I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Type 2
"I take shots (insulin) for my diabetes" Insulin Dependent Diabetes Mellitus
(IDDM)
Type 1
Layman's Thyroid problem Hypothyroidisim
Layman's Heart Disease Coronary Artery Disease (CAD)
Layman's Heart attack Myocardial Infraction (MI) and CAD
Layman's heart failure Congestive heart failure (CHF)
Layman's irregular heartbeat arrhythmia
Layman's emphysema or chronic bronchitis Chronic Obstructive Pulmonary Disease (COPD)
Layman's Blood clot in lung Pulmonary Embolism (PE)
Layman's reflux Gastroesophageal Reflux Disease (GERD)
Layman's Ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Layman's bladder infection Urinary Tract Infection (UTI)
Layman's Kidney Infection Pyelonephritis
Layman's Kidney Stones Renal Calculi
Layman's "Im on dialysis" Chronic Kidney Disease (CKD) on dialysis
Layman's enlarged prostate Benign Prostatic Hyperplasia (BPH)
