Scribe America Outpatient Course 5,
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diagnosis - 🧠ANSWER ✔✔What the physician has determined to be the
most likely cause of
the patient's symptoms
assessment - 🧠ANSWER ✔✔A list of the patient's current diagnoses
plan - 🧠ANSWER ✔✔The currently laid out course of action to address the
patient's
condition.
,prognosis - 🧠ANSWER ✔✔A forecast of the likely course of a disease or
ailment
follow up - 🧠ANSWER ✔✔On-going contact with healthcare providers in
order to address a
health concern
assessment - 🧠ANSWER ✔✔diagnosis + summary of visit
Before seeing a patient, the doctor typically reviews the
assessment from the previous visit.
assessment - 🧠ANSWER ✔✔The assessment will vary significantly based
on specialty, clinic, and provider preference.
The assessment always includes: Diagnosis- and/or differentials
And may also include: Brief summary of the HP-Typically chief complaint
and onset only
,Brief summary of physical exam-Pertinent findings only
Summary of lab/imaging results-If new since the last visit
Prognosis: Or justification for further testing or
medication
Assessment - 🧠ANSWER ✔✔Example of a simple assessment: "Pt is a 26
y/o male with cough."
Example of comprehensive assessment:
"Pt is a 57 y/o female with primary pulmonary hypertension, first diagnosed
two years
ago. Based on the physical exams from past two visits, she does appear to
be
3
COPYRIGHT©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
, somewhat worsening. Echocardiogram and symptoms are suggestive of
idiopathic
pulmonary hypertension and she appears to be functional class III. The
recent VQ scan and CT angiogram did not demonstrate any evidence of
thromboembolic
pulmonary hypertension. She will require right and left heart catheterization
for
evaluation of pulmonary artery pressures, cardiac output, and left
ventricular end-diastolic pressure."
assessment structure - 🧠ANSWER ✔✔simple statement
brief summary
comprehensive summary
the assessment is typically written in complete sentences
ASSESSMENT STRUCTURE - 🧠ANSWER ✔✔Simple Statement
ScribeAmerica Outpatient Course 4,
ScribeAmerica OP Course 3,
ScribeAmerica OP Course 2,
ScribeAmerica OP Course 1
diagnosis - 🧠ANSWER ✔✔What the physician has determined to be the
most likely cause of
the patient's symptoms
assessment - 🧠ANSWER ✔✔A list of the patient's current diagnoses
plan - 🧠ANSWER ✔✔The currently laid out course of action to address the
patient's
condition.
,prognosis - 🧠ANSWER ✔✔A forecast of the likely course of a disease or
ailment
follow up - 🧠ANSWER ✔✔On-going contact with healthcare providers in
order to address a
health concern
assessment - 🧠ANSWER ✔✔diagnosis + summary of visit
Before seeing a patient, the doctor typically reviews the
assessment from the previous visit.
assessment - 🧠ANSWER ✔✔The assessment will vary significantly based
on specialty, clinic, and provider preference.
The assessment always includes: Diagnosis- and/or differentials
And may also include: Brief summary of the HP-Typically chief complaint
and onset only
,Brief summary of physical exam-Pertinent findings only
Summary of lab/imaging results-If new since the last visit
Prognosis: Or justification for further testing or
medication
Assessment - 🧠ANSWER ✔✔Example of a simple assessment: "Pt is a 26
y/o male with cough."
Example of comprehensive assessment:
"Pt is a 57 y/o female with primary pulmonary hypertension, first diagnosed
two years
ago. Based on the physical exams from past two visits, she does appear to
be
3
COPYRIGHT©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
, somewhat worsening. Echocardiogram and symptoms are suggestive of
idiopathic
pulmonary hypertension and she appears to be functional class III. The
recent VQ scan and CT angiogram did not demonstrate any evidence of
thromboembolic
pulmonary hypertension. She will require right and left heart catheterization
for
evaluation of pulmonary artery pressures, cardiac output, and left
ventricular end-diastolic pressure."
assessment structure - 🧠ANSWER ✔✔simple statement
brief summary
comprehensive summary
the assessment is typically written in complete sentences
ASSESSMENT STRUCTURE - 🧠ANSWER ✔✔Simple Statement
