Exam (elaborations)
Scribe OP final exam with 100% correct answers
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Scribe OP final exam with 100% correct answers
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ScribeOP
final
exam
subjective
vs
objective
-
ANS-feeling
vs.
fact
pain
vs
tenderness
-
ANS-patient's
feeling
vs.
physician's
assessment
benign
-
ANS-Normal,
nothing
of
concern
acute
vs
chronic
-
ANS-new
onset
vs
long
standing
baseline
-
ANS-An
individual's
normal
state
of
being
Auscultation
-
ANS-Listening
with
a
stethoscope
Palpation
-
ANS-The
act
of
pressing
on
an
area
(by
the
physician)
inpatient
-
ANS-Admitted
to
the
hospital
overnight
outpatient
-
ANS-seen
and
sent
home
the
same
day
chief
complaint
-
ANS-the
main
reason
for
the
patient's
visit
meaningful
use
-
ANS-a
set
of
government
mandated
criteria
that
must
be
obtained
for
every
patient
medical
decision
making
-
ANS-the
physician's
thought
process
give
two
examples
of
mid-level
providers
-
ANS-LPN,
PA
what
tasks
can
you
complete
as
a
scribe:
-document
the
history
and
physical
exam
while
the
physician
performs
them
-help
a
patient
from
his
wheelchair
to
the
exam
chair
-locate
previous
results
to
show
the
provider
-sign
the
doctor's
charts
at
the
end
of
the
day
-
ANS--document
the
history
and
physical
exam
while
the
physician
performs
them
-locate
previous
results
to
show
the
provider a
chart
for
an
established
patient
will
be________
than
the
chart
for
a
new
patient
-
ANS-longer
in
a
diagnostic
visit,
the
patient
has
a
________
complaint
-
ANS-new
who
typically
obtains
meaningful
use
requirements
during
patient
check-in?
-
ANS-MA/nurse
H&P
stands
for
_____
&
______
and
is
part
of
the
________
evaluation
-
ANS-history
&
physical,
provider
name
two
items
you
will
include
in
the
patient's
plan
-
ANS-medications,
treatment
If
the
doctor
tells
you,
"The
lungs
are
clear,"
where
would
you
document
this?
-
ANS-physical
exam
"I
have
high
blood
pressure"
-->
you
would
write....
-
ANS-HTN
"I
take
shots
for
my
diabetes"
-->
you
would
write....
-
ANS-IDDM
"My
doctor
says
my
heart
is
failing."
-->
you
would
write....
-
ANS-CHF
"I
have
acid
reflux"
-->
you
would
write....
-
ANS-GERD
"I'm
not
pregnant.
I
have
two
children,
but
I
miscarried
my
first
pregnancy"
-->
you
would
write....
-
ANS-G:
3/
P:2
/
A:1
"I
had
a
mini-stroke
last
year"
-->
you
would
write....
-
ANS-TIA
heart
bypass
surgery
-
ANS-coronary
artery
bypass
graft
breast
removal
surgery
-
ANS-mastectomy
gallbladder
removed
surgery
-
ANS-cholecystectomy
uterus
removed
surgery
-
ANS-tubal
ligation
neck
artery
cleaned
surgery
-
ANS-carotid
endarterectomy common
general
family
histories
that
physicians
frequently
ask
about
-
ANS-HTN,
DM,
CA
SHx
Living
Circumstances
-
ANS-lives
alone,
with
family/friends,
nursing
home/assisted
living,
hospice,
homeless/shelter
Comorbidity
-
ANS-the
simultaneous
presence
of
two
chronic
diseases
or
conditions
in
a
patient
etiology
-
ANS-cause
of
disease
systole
-
ANS-the
phase
of
the
heartbeat
when
the
heart
muscle
contracts
and
pumps
blood
from
the
chambers
into
the
arteries.;
pumping
blood
to
the
body
diastolic
-
ANS-phase
of
the
heartbeat
during
which
muscle
is
relaxed
and
the
heart
fills
with
blood
diuretic
-
ANS-A
substance
that
promotes
the
production
of
urine
paresthesia
-
ANS-sensation
of
tingling
or
numbness
polydipsia
-
ANS-excessive
thirst
ischemia
-
ANS-loss
of
blood
supply
to
tissue
anticoagulant
-
ANS-a
drug
that
prevents
blood
clotting
(blood
thinner)
how
long
must
a
patient
have
a
disease
for
it
to
be
considered
chronic?
-
ANS-3
months
explain
why
patients
with
comorbidities
are
complex
and
give
an
example
-
ANS--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
-if
both
illnesses
affect
a
specific
organ
system,
the
patient
is
at
increased
risk
of
organ
failure
ex:
might
have
DM
and
high
BP
Complex
patients
often
bill
to
a______level,
so
it's
important
to
document
thoroughly
and
accurately
-
ANS-higher
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