Scribe America Final Exam OP With 100% Complete Answers.
Scribes CAN - 1. Document the history, physical exam, results, procedures, and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT - -touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC) - the main reason for the patient's visit
EMR / EHR - Electronic Medical Record / Electronic Health Record
Subjective - feelings of the patient
Objective - factual findings from the provider
pain - patients feeling of discomfort
tenderness - doctors finding of reproducible pain
acute - New onset, likely concerning
https://www.stuvia.com/
,chronic - Long-standing, not of direct concern
new patient (NP) - a patient that has never been seen at the clinic or was seen greater than 3 years
ago.
no previous records.
longer visits.
detailed chart.
established patient (EP) - a patient that has been seen at the clinic by any provider within the last 3
years.
previous records available.
shorter visits.
concise chart.
Diagnostic visit - New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit - 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
https://www.stuvia.com/
, History of Present Illness (HPI) - The story and context of the Chief Complaint (subjective)
Review of Systems (ROS) - A head-to-toe list of positives and negatives (subjective)
Past history - PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examination (PE) - The physician's objective findings
Orders and Results - objective evaluation
Assessment - current diagnoses
plan - treatment plan and follow up
high blood pressure - Hypertension (HTN)
high cholesterol - Hyperlipidemia (HLD)
diabetes - Diabetes Mellitus (DM)
"I only take pills for my diabetes" - Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes" - Insulin Dependent Diabetes Mellitus (IDDM)
heart disease - Coronary Artery Disease (CAD)
heart attack - Myocardial Infarction (MI) and CAD
heart failure - Congestive Heart Failure (CHF)
Irregular heartbeat - Arrhythmia, Atrial Fibrillation (A-Fib)
https://www.stuvia.com/
Scribes CAN - 1. Document the history, physical exam, results, procedures, and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT - -touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC) - the main reason for the patient's visit
EMR / EHR - Electronic Medical Record / Electronic Health Record
Subjective - feelings of the patient
Objective - factual findings from the provider
pain - patients feeling of discomfort
tenderness - doctors finding of reproducible pain
acute - New onset, likely concerning
https://www.stuvia.com/
,chronic - Long-standing, not of direct concern
new patient (NP) - a patient that has never been seen at the clinic or was seen greater than 3 years
ago.
no previous records.
longer visits.
detailed chart.
established patient (EP) - a patient that has been seen at the clinic by any provider within the last 3
years.
previous records available.
shorter visits.
concise chart.
Diagnostic visit - New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit - 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
https://www.stuvia.com/
, History of Present Illness (HPI) - The story and context of the Chief Complaint (subjective)
Review of Systems (ROS) - A head-to-toe list of positives and negatives (subjective)
Past history - PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examination (PE) - The physician's objective findings
Orders and Results - objective evaluation
Assessment - current diagnoses
plan - treatment plan and follow up
high blood pressure - Hypertension (HTN)
high cholesterol - Hyperlipidemia (HLD)
diabetes - Diabetes Mellitus (DM)
"I only take pills for my diabetes" - Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes" - Insulin Dependent Diabetes Mellitus (IDDM)
heart disease - Coronary Artery Disease (CAD)
heart attack - Myocardial Infarction (MI) and CAD
heart failure - Congestive Heart Failure (CHF)
Irregular heartbeat - Arrhythmia, Atrial Fibrillation (A-Fib)
https://www.stuvia.com/
