ScribeAmerica OP Final Exam flashcards with questions and
rationales.
pain vs tenderness - patient's feeling vs physician's assessment
acute vs chronic - new onset vs long standing
Meaningful Use (MU) - a set of government mandated criteria that must be obtained for every
patient
Medical decision making - the physician's thought process
Mid-level providers: - Nurse Practitioner (LNP) or Physician's Assistant (PA) that works under the
supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - records medical histories and symptoms, monitors the patient,
completes meaning use requirements, administers medications, assists with procedures
Receptionist - answers phone calls, schedules appointments, answers patient questions, provides
patient with summary of visit and written instructions from provider at check-out, and organizes the
patient's paperwork
Scribe - documents the patient's visit on behalf of the physician
Scribes CANNOT... - -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
Scribes CAN... - -document the history, physical exam, results, procedures, assessment and plan
https://www.stuvia.com/
,-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
New patients - -no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new
Established patients - -previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years
Diagnostic visit - -new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary
Health Maintenance visit - -check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems
allergy - a medication that causes a rash, itching, swelling, or difficulty breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy
Hypertension (HTN) - high blood pressure
Hyperlipidemia (HLD) - high cholesterol
Normal heart rate - 60-100 bpm
https://www.stuvia.com/
, Pulmonary Embolism (PE) - blood clot in lung
Gravida/Para/Abortion - G - the total number of times the patient has been pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions
Cerebrovascular Accident (CVA) - stroke
Transient Ischemic Attack (TIA) - mini-stroke
Tonsillectomy - tonsils removed
Adenoidectomy - adenoids removed
Coronary Artery Bypass Graft - heart bypass (PMHx CAD)
Angioplasty - balloon
Automatic Implanted Cardiac-Defribrillator (AICD) - defibrillator
Mastectomy - breast removal
Partial Lobectomy - part of lung removed
Appendectomy - appendix removed
Cholecystectomy - gallbladder removed
Herniorrhaphy - hernia repair
https://www.stuvia.com/
rationales.
pain vs tenderness - patient's feeling vs physician's assessment
acute vs chronic - new onset vs long standing
Meaningful Use (MU) - a set of government mandated criteria that must be obtained for every
patient
Medical decision making - the physician's thought process
Mid-level providers: - Nurse Practitioner (LNP) or Physician's Assistant (PA) that works under the
supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - records medical histories and symptoms, monitors the patient,
completes meaning use requirements, administers medications, assists with procedures
Receptionist - answers phone calls, schedules appointments, answers patient questions, provides
patient with summary of visit and written instructions from provider at check-out, and organizes the
patient's paperwork
Scribe - documents the patient's visit on behalf of the physician
Scribes CANNOT... - -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
Scribes CAN... - -document the history, physical exam, results, procedures, assessment and plan
https://www.stuvia.com/
,-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
New patients - -no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new
Established patients - -previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years
Diagnostic visit - -new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary
Health Maintenance visit - -check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems
allergy - a medication that causes a rash, itching, swelling, or difficulty breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy
Hypertension (HTN) - high blood pressure
Hyperlipidemia (HLD) - high cholesterol
Normal heart rate - 60-100 bpm
https://www.stuvia.com/
, Pulmonary Embolism (PE) - blood clot in lung
Gravida/Para/Abortion - G - the total number of times the patient has been pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions
Cerebrovascular Accident (CVA) - stroke
Transient Ischemic Attack (TIA) - mini-stroke
Tonsillectomy - tonsils removed
Adenoidectomy - adenoids removed
Coronary Artery Bypass Graft - heart bypass (PMHx CAD)
Angioplasty - balloon
Automatic Implanted Cardiac-Defribrillator (AICD) - defibrillator
Mastectomy - breast removal
Partial Lobectomy - part of lung removed
Appendectomy - appendix removed
Cholecystectomy - gallbladder removed
Herniorrhaphy - hernia repair
https://www.stuvia.com/
