Scribe Final Exam Questions and Answers Rated A

Scribe Final Exam Questions and Answers Rated A SOAP Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) Assessment-Diagnosis (determined by combining subjective/objective info) Plan-Disposition (Admission, Discharge, Transfer instructions) 7 Parts of the HPI 1. Context 2. Time/Duration; time = course of symptoms (improving, worsening, constant, intermittent, etc.); duration = total time symptoms have been present 3. Location 4. Quality 5. Severity 6. Modifying Factors 7. Pertinent positive and negatives Level 5 Chart HPI: 4-7 ROS: 10+ PFSH: 2+ PEx: 8+ systems Supination Turning the hand so that the palm faces upward. Volar Pertaining to the palm of the hand or the sole of the foot. Inferior Situated below or further away from the head. Midline Line that divides the body into right and left halves. Abduction Moving away from the midline. ACLS Advanced cardiac life support. AMA Against medical advice. DNR do not resuscitate DOA Dead on arrival OSH Outside hospital PCP Primary care physician PTA Prior to arrival UTD Up to date (as in immunizations) WNL within normal limits yo year old B/L bilateral D/C discharge H&P history & physical nl normal s/p status post TTP tenderness to palpation Proximal closer to the body Lateral farther from the midline Extension straightening out Distal farther from the body Adduction Draws toward the midline Pronation turning of the hand so the palm faces downward Posterior situated behind or directed towards the rear Plantar referring to the sole of the foot Inverted turned inward Deep Farther from the surface Flexion bending or angulation Percussion physician taps on a surface to determine the underlying structure