ScribeAmerica Final Exam ED (100% Errorless Answers)

What are the 3 types of dispositions? correct answers Discharge, Admit, Transfer What does HPI stand for? correct answers history of present illness What does ROS stand for? correct answers review of systems The HPI and ROS are considered what type of information? correct answers subjective The physical exam is what type of information? correct answers objective If a physician told you a patient's abdomen was non tender, where would you document this? correct answers PE What section focuses directly on the chief complaint? correct answers HPI If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? correct answers CAD Name an example of something you may write in the Social Hx portion of the chart. correct answers smokes 1 pack/day Name an example of something you may write in the Family Hx portion of the chart. correct answers Mother had Hx of CAD at age 46 What are the abbreviations for the following past medical history terms? Hypertension Stroke Diabetes Heart Attack High Cholesterol correct answers HTN CVA (cerebrovascular accident) DM MI HLD What are the medical terms for the following past surgical terms? Removal of the appendix Removal of the gallbladder Removal of the uterus Removal of a fallopian tube Removal of the tonsils Removal of the breast correct answers appendectomy cholecystectomy hysterectomy