Scribe America outpatient Final Exam 1 Questions With Correct Answers

Subjective - Answer Feeling, pain, CC, HPI, ROS Objective - Answer Fact, tenderness, PE, results pain - Answer pt's feeling tenderness - Answer physician assessment benign - Answer normal, nothing of concern acute - Answer new onset chronic - Answer long-standing; more than 3 months auscultation - Answer listening with stethoscope palpation - Answer pressing on an area (physician) inpatient - Answer admitted to hospital overnight outpatient - Answer seen and sent home same day chief complaint - Answer main reason for pt's visit. Must be in HPI. meaningful use - Answer government mandated criteria, must be obtained for every patient. Smoking status, vitals (HR, BP, T, RR), height, weight, BMI. medical decision making - Answer physician's thought process: r/o, worst first mid-level provider - Answer nurse practitioner, physician assistant, do Dx and Tx under supervision of physician nurse or medical assistant - Answer record Hx, Sx, monitor pt, meaningful use, gives meds, assists with procedures scribe - Answer clerical, not clinical. Can clean if no fluids. Cannot touch pt ever. scribes CAN - Answer document, access and document lab results and radiology, locate and obtain PMHx, previous charts, past results, recent studies, record physician interpretations of tests (X-rays, EKGs) scribes CANNOT - Answer affect pt health, touch pt, handle bodily fluids or specimens, sign or authenticate a chart or record, give verbal orders, submit electronic orders new pt - Answer longer visit, detailed chart, new if not seen in 3 years established pt - Answer shorter visit, previous records, concise chart, established if new to provider but not new to clinic/group diagnostic, health maintenance - Answer types of clinic visits clinic flow - Answer check-in, physician evaluation, orders and results, assessment and plan, check-out check-in - Answer meaningful use by nurse, nurse assessment (confirm CC, review allergies/meds, brief PMHx). Changes in meds would go in HPI. physician eval - Answer review assessment and plan from last visit, labs and imaging results, H&P (HPI, ROS, PE), differential Dx if diagnostic visit orders and results - Answer lab studies, imaging studies, procedures (only document these if done by physician). assessment and plan - Answer list of Dx; follow-up with specialist, preventative care, next for next appointment check-out - Answer home vs ED; pt education provided; schedule follow-up CC exs - Answer pt came to clinic for CP; pt has suffered from HTN for many years ROS exs - Answer pt also stubbed his toe last week PHx exs - Answer PMHx, PSHx, Sx, Fx. The pt's mother has heart disease. Would go in HPI as well if pt mentions it as part of reason for visit. PE exs - Answer pt is in no acute distress; tenderness of the RUQ results exs - Answer CBC shows anemia; EKG shows Normal Sinus Rhythm assessment and plan exs - Answer CBC shows anemia; Dx is URI; pt will be prescribed penicillin today medical allergy - Answer rash, itching, swelling, difficulty breathing adverse reaction - Answer any unwanted reaction to a medicine that is not a true allergy (rash, itching, swelling, dyspnea) HTN hypertension - Answer high BP HLD hyperlipidemia - Answer high cholesterol hypo/hyperthyroidism - Answer thyroid problem DM - Answer diabetes NIDDM, type 2, 95%, adult onset - Answer I only take pills for my diabetes IDDM, type 1, 5%, childhood onset - Answer I take insulin shots for my diabetes CAD coronary artery Dz - Answer heart Dz MI myocardial infarction and CAD - Answer heart attack