Scribe America Outpatient Course 1 Exam Questions With Correct Answers

Subjective vs. objective: - Answer Feeling vs. fact Pain vs. tenderness - Answer Patient's feeling vs. physician's assessment Benign - Answer Normal, nothing of concern Acute - Answer New onset, likely concerning Chronic - Answer Long-standing, not of direct concern Baseline - Answer An individual's normal state of being Auscultation - Answer Listening with a stethoscope Palpation - Answer The 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 The main reason for the patient's visit Mid-Level Provider - Answer Nurse Practitioner (LNP) or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients Medical provider - Answer Mid-level provider that diagnoses and treats patients Nurse or Medical Assistant - Answer Records medical histories and symptoms, monitors the patient, completes the meaningful use requirements, administers medications, assists with procedures Clinical provider - Answer Includes both the mid-level provider and nurse or medical assistant that are direct patient care Scribe - Answer Documents the patient's visit on behalf of the physician Clerical - Answer Receptionist and scribe that there is no patient care and only documentation Scribes CAN.... - Answer -Document the history, physical exam, results, procedures, assessment, and plan -Access and document laboratory results and radiology findings -Locate and obtain PMHx, previous charts, past results, and recent studies -Record physician interpretations of x-rays and EKGs Assessment vs Plan - Answer Diagnosis vs Treatment Scribes CANNOT... - Answer -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 -NO direct patient care, No patient samples, No using logins other than your own NEW Patient - Answer No previous records, Longer visit, and Detailed chart ESTABLISHED Patient - Answer Previous records available, Shorter visit, and Concise chart Diagnostic Visit - Answer New problem, Chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment Health Management Visit - Answer Check-up, Chief Complaint: Routine physical or management of chronic problem(s), and Goal is preventative care and/or assessing progress of ongoing medical problems CLINIC FLOW - Answer Check in -> Physical evaluation -> Orders & Results -> Assessment & Plan -> Check Out CLINIC FLOW - CHECK-IN - Answer Patient Walks in (Diagnostic vs. Health Management) -> Room Placement -> Meaningful Use obtained by Nurse/MA (Chief complaint, Vital signs: HR, BP, T, RR), Height, Weight, BMI, Smoking Status) -> Nurse/MA Assessment (Confirm chief complaints, review allergies/medications , brief past medical history) CLINIC FLOW - PHYSICIAN EVAL - Answer Review the patient's medical records (Assessment & plan from the previous visit, Labs and/or imaging results) -> History and Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the symptoms) CLINIC FLOW - ORDERS & RESULTS - Answer Orders (Laboratory studies, Imaging studies, and Procedures) -> Results (May result during visit (rare) or in a few days) CLINIC FLOW - ASSESSMENT & PLAN - Answer Assessment (The list of diagnoses) -> Plan (Follow-up with specialist if necessary, Instructions for lifestyle and preventative care, and Follow-up for next routine appointment) CLINIC FLOW - CHECK-OUT - Answer Check-out (Home vs. sent to the ED, Patient education provided, and Patient will often stop at the front desk on the way out to schedule next appointment) SECTIONS OF A CHART - Answer S (Subjective), O (Objective), A (assessment), and P (Plan) Past diagnosis or surgery - Answer Past History Physician's observation - Answer Physical Exam High blood pressure - Answer Hypertension (HTN) High cholesterol - Answer Hyperlipidemia (HLD) Thyroid problem - Answer Usually Hypothyroidism, sometimes Hyperthyroidism Diabetes - Answer Diabetes Mellitus (DM) "I only take pills for my diabetes" - Answer Non-Insulin Dependent Diabetes Mellitus (NIDDM) "I take shots (insulin) for my diabetes" - Answer Insulin Dependent Diabetes Mellitus (IDDM) Heart disease - Answer Usually Coronary Artery Disease (CAD) Heart attack - Answer Myocardial Infarction (MI) and CAD Heart failure - Answer Congestive Heart Failure (CHF)