Scribe America OP Final Exam 2023 with 100% correct answers

scribes can document the SOAP scribes cannot partake in any activity that may affect patient health or outcome; touch patients; handle bodily fluids or specimens; sign or authenticate any chart or record; give verbal orders or submit electronic orders new patient no previous records; longer visit; detailed chart established patient previous records available; shorter visit; concise chart diagnostic clinic visit new problem; cc: new symptom; goal is to determine the cause of the problem and appropriate treatment health maintenance clinic visits check-up; cc: management of {insert chronic problem}; goal is to assess progress of on-going/chronic medical problems clinic flow check-in, physician evaluation, orders & results, assessment & plan, check-out meaningful use includes cc; vital signs: HR, BP, T, RR; height, weight, BMI; smoking status nurse/MA assessment confirm chief complaint; review allergies/medications' brief past medical history history and physical (H&P) includes HPI, ROS, PE orders include laboratory studies, imaging studies, procedures results include may result during visit (rare) or in a few days assessment the list of diagnoses plan follow-up with specialist if necessary; instructions for lifestyle and preventative care; follow-up for next routine appointment check-out home vs sent to the ED; patient education provided; patient will often stop at the front desk on the way out to schedule next appointment social history includes tobacco use; alcohol use; illicit drug use; occupation; living circumstances smoking status current, former, never, second-hand exposure alcohol use status never, occasionally'socially, daily, chronic alcoholic occupation status employed, unemployed, on disability living circumstances status lives alone; with family/friends; nursing home'assisted living; hospice; homeless/shelter