ScribeAmerica Outpatient Final Exam Questions & Answers Solved 100%

subjective vs objective - Answer feeling vs fact pain vs tenderness - Answer patients feeling vs physicians assessment benign - Answer normal, nothing of concern acute vs chronic - Answer new onset vs long standing baseline - Answer an individuals normal state of being ausculation - Answer listening to sound with a stethoscope palpation - Answer act of pressing on an area (by the physician) inpatient - Answer admitted to the hospital overnight outpatient - Answer seen and sent home the same day chief complaint - Answer main reason for the patients visit meaningful use - Answer set of government mandated criteria that must be obtained for every patient medical decision making - Answer physicians though process Scribes can... - Answer document history, physician exam, results, procedures. access and document laboratory and radiology findings. locate and obtain PMHx, previous charts, past results. Scribes cannot... - Answer partake in any activity that may affect patient health, touch patients, handle bodily fluids, sign any charts, give verbal orders or submit electronic orders. are physician assistants and nurse practitioners considered medical providers? - Answer YES T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning purposes and under the supervision of the physician. - Answer False Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine appointment with Dr. Heart. Is Lucy a new or established patient? - Answer Established a patient made an appointment because she developed a rash a few days ago. what type of visit would this be? - Answer diagnostic diagnostic visits consist of - Answer new problems, new symptoms health management visits consist of - Answer check-ups, management visits a patient has an appointment for management of her diabetes. what type of visit would this be? - Answer health management who is the first person to speak with the patient after he/she is place in a room? - Answer Nurse/MA What are the meaningful use requirements the nurse/MA will obtain? - Answer Chief complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking status What does H&P abbreviate and who performs this evaluation? - Answer history and physical, performed by the provider Is a differential diagnosis necessary for a health maintenance visit? - Answer nope. what information will be included in the patient's plan? give 3 examples. - Answer F/U for specialist, instructions for lifestyle, F/U for next routine appointment name the 8 elements of the HPI - Answer Location, Quality, Severity, Context, Timing, Duration, Associated signs and symptoms, Modifying factors polydipsia - Answer excessive thirst paresthesia - Answer sensation of tingling or numbness anticoagulant - Answer a drug that prevents blood clotting chronic illness - Answer longer than 3 months if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered chronic? - Answer No Having multiple comorbidities increases the __________ of patient care - Answer complexity List two ways comorbidity increases complexity? - Answer -The treatment of one disease may affect or contradict the treatment of the second -Adverse drug interactions -Compounding symptoms may lead to poor compliance with treatment plan (mo' drugs, mo' problems) -If both illnesses affect a specific organ system, the patient is at increased risk of organ failure Type 2 diabetes - Answer the inadequacy of insulin in controlling the blood glucose level (insulin resistance) diabetes risk factors - Answer obesity, high carb diet, lack of exercise, HTN, HLD, FHx chief complaint of diabetes - Answer weight loss or gain. polyuria, polydipsia, blurred vision, fatigue physical exam diabetes - Answer distal paresthesias, pedal edema, weight change diagnosis of diabetes - Answer fasting blood glucose, hemoglobin A1c Diseases caused by diabetes - Answer peripheral neuropathy, PVD, Diabetic retinopathy, renal failure, cardiac disease non-pharmacological management for DM - Answer weight loss, low-carb diet, exercise, blood glucose log you can take oral medication for what kind of diabetes? - Answer type 2 (you can do insulin and oral meds) what kind of medications can you take for DM? - Answer Injected: Humalog, Lantus Oral: Metformin, Glyburide with sliding scale insulin treatment, the patient adjusts the dosage of insulin based on____________. - Answer current glucose Name two body systems that would be at increased risk of failure if the patient had both HTN and DM. - Answer renal and cardiovascular SOAP - Answer subjective, objective, assessment, plan History of Present Illness (HPI) - Answer story of the patient's chief complaint What are the 3 primary methods of structuring an outpatient HPI? - Answer Single complaint formula, multiple complain formula, chronological complain formula Which HPI structure is best to use for a complex patient with multiple comorbidities and a recent work-up? - Answer chronological What are four important details to include in the HPI of a patient who has been evaluated by another healthcare provider for similar symptoms? - Answer Who ordered the test (name and specialty), specific name of test, results, diagnosis given to patient. review of systems - Answer Head-to-toe checklist of patient's symptoms intermittent - Answer comes and goes waxing and waning - Answer always present but changing in intensity modifying factor - Answer something that makes a symptoms better or worse exacerbate - Answer to make worse Subjective includes what? - Answer chief complaint, HPI, ROS Where is the past history? - Answer PMHx, SHx, FHx are their own section under the S and above the O Objective includes what? - Answer vital signs, PE, Orders, Results Assessment includes what? - Answer the patient's diagnosis, description of progress since last visit Plan includes what? - Answer F/U and treatment for each diagnosis T/F: The structure of the SOAP note closely follows the clinic flow - Answer True T/F: You will usually document the assessment before documenting the HPI? - Answer False The doctor says to the patient, "I'd like you to follow up with your GI doctor in the next two weeks." In what section of the SOAP note does this belong? - Answer Plan Importance of the chief complaint - Answer its what brought the patient in, ALSO, billing, w/o it, you cant be reimbursed what words can you add to your chief complaint to make it reimbursable - Answer management or treatment. (ex. 3 month diabetes management visit, Discuss treatment options for elevated TSH, evaluation of medication management for HTN) The HPI is the... - Answer story and context of the patient's chief complaint T/F: Abbreviations are permitted in the HPI as long as they are approved medical abbreviations - Answer True T/F: It is okay for scribes to misspell words because doctors do it all the time - Answer False How would you document the onset of symptoms that began on Wednesday? - Answer x days ago If the patient says, "It hurts when I touch it," what would you write in the HPI? - Answer Symptoms worsened by palpation of the area. thyroid problem - Answer hypothyroidism or hyperthyroidism it only take pills for my diabetes - Answer non-insulin dependent diabetes mellitus (NIDDM) heart disease - Answer Usually Coronary Artery Disease (CAD) heart attack - Answer Myocardial Infarction (MI) and CAD heart failure - Answer Congestive Heart Failure (CHF) irregular heartbeat - Answer Atrial Fibrillation (A-Fib) Episodes of abnormally fast/racing heartbeat - Answer Supraventricular Tachycardia (SVT) emphysema/chronic bronchitis - Answer Chronic Obstructive Pulmonary Disease (COPD) blood clot in the lung - Answer Pulmonary Embolism (PE)