Scribe America Final Exam OP(100%
Correct)
Subjective - ANSWERSPatient feeling
objective - ANSWERSprovider fact
pain - ANSWERSpatient's feeling
tenderness - ANSWERSprovider assessment
baseline - ANSWERSan individual's normal state of being
auscultation - ANSWERSlistening with a stethoscope
palpation - ANSWERSthe act of pressing on an area by provider
inpatient - ANSWERSadmitted overnight
outpatient - ANSWERSseen and sent home the same day
chief complaint - ANSWERSmain reason for patient's visit
meaningful use - ANSWERSset of gov't mandated criteria that must be obtained for
every patient
medical decision making - ANSWERSphysician's thought process
new patients - ANSWERSlonger visit, concise chart
established patients - ANSWERSshorter visit, concise chart
diagnostic visit - ANSWERSvisit for a new problem; CC is a new symptom; determine
cause of problem and appropriate treatment
health maintenance visit - ANSWERScheck up; CC management of chronic problem;
assess progress of ongoing/chronic problem; preventative care
SOAP - ANSWERSsubjective, objective, assessment, plan
subjective section - ANSWERSincludes history of present illness, review of systems
, history of present illness - ANSWERSstory and context of chief complaint
objective evaluation - ANSWERSphysical examination, orders and results
assessment section - ANSWERSdiagnoses
plan section - ANSWERStreatment and follow up
"high blood pressure" - ANSWERShypertension - HTN
"high cholesterol" - ANSWERShyperlipidemia - HLD
"thyroid problem" - ANSWERShypothyroidism or hyper
"kidney stones" - ANSWERSrenal calculi
"I'm on dialysis" - ANSWERSChronic renal failure - CRF
"enlarged prostate" - ANSWERSbenign prostatic hypertrophy - BPH
"seizures" - ANSWERSSeizure disorder/epilepsy
Brain bleed - ANSWERShemorrhagic CVA
"I drink a lot" - ANSWERSETOH abuse or alcoholism
"Bipolar" - ANSWERSbipolar disorder
"blood clot in my leg" - ANSWERSlower extremity DVT
"Bulge in my aorta" - ANSWERSabdominal aortic aneurysm - AAA
"bad blood flow to my legs" - ANSWERSperipheral vascular disease PVD
"low back pain" - ANSWERSchronic low back pain
bulging/herniated disc - ANSWERSdegenerative disc disease DDD
"arthritis" - ANSWERSosteoarthritis OA or rheumatoid arthritis RA
"joint pain (chronic)" - ANSWERSdegenerative joint disease DJD
"weak/fragile bones" - ANSWERSosteoporosis
"spread to my..." - ANSWERSmetastasis to the...
Correct)
Subjective - ANSWERSPatient feeling
objective - ANSWERSprovider fact
pain - ANSWERSpatient's feeling
tenderness - ANSWERSprovider assessment
baseline - ANSWERSan individual's normal state of being
auscultation - ANSWERSlistening with a stethoscope
palpation - ANSWERSthe act of pressing on an area by provider
inpatient - ANSWERSadmitted overnight
outpatient - ANSWERSseen and sent home the same day
chief complaint - ANSWERSmain reason for patient's visit
meaningful use - ANSWERSset of gov't mandated criteria that must be obtained for
every patient
medical decision making - ANSWERSphysician's thought process
new patients - ANSWERSlonger visit, concise chart
established patients - ANSWERSshorter visit, concise chart
diagnostic visit - ANSWERSvisit for a new problem; CC is a new symptom; determine
cause of problem and appropriate treatment
health maintenance visit - ANSWERScheck up; CC management of chronic problem;
assess progress of ongoing/chronic problem; preventative care
SOAP - ANSWERSsubjective, objective, assessment, plan
subjective section - ANSWERSincludes history of present illness, review of systems
, history of present illness - ANSWERSstory and context of chief complaint
objective evaluation - ANSWERSphysical examination, orders and results
assessment section - ANSWERSdiagnoses
plan section - ANSWERStreatment and follow up
"high blood pressure" - ANSWERShypertension - HTN
"high cholesterol" - ANSWERShyperlipidemia - HLD
"thyroid problem" - ANSWERShypothyroidism or hyper
"kidney stones" - ANSWERSrenal calculi
"I'm on dialysis" - ANSWERSChronic renal failure - CRF
"enlarged prostate" - ANSWERSbenign prostatic hypertrophy - BPH
"seizures" - ANSWERSSeizure disorder/epilepsy
Brain bleed - ANSWERShemorrhagic CVA
"I drink a lot" - ANSWERSETOH abuse or alcoholism
"Bipolar" - ANSWERSbipolar disorder
"blood clot in my leg" - ANSWERSlower extremity DVT
"Bulge in my aorta" - ANSWERSabdominal aortic aneurysm - AAA
"bad blood flow to my legs" - ANSWERSperipheral vascular disease PVD
"low back pain" - ANSWERSchronic low back pain
bulging/herniated disc - ANSWERSdegenerative disc disease DDD
"arthritis" - ANSWERSosteoarthritis OA or rheumatoid arthritis RA
"joint pain (chronic)" - ANSWERSdegenerative joint disease DJD
"weak/fragile bones" - ANSWERSosteoporosis
"spread to my..." - ANSWERSmetastasis to the...
