ScribeAmerica OP Final Exam with correct and complete answers

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 -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 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 Colostomy bag to collect stool Splenectomy spleen removed Hysterectomy Uterus removed (partial or total) Oophorectomy ovary removed Salpingo-oophorectomy ovary and fallopian tubes removed Prostatectomy prostate removed Nephrectomy kidney removed Arteriovenous Fistula directly connecting an artery to a vein Arteriovenous Graft synthetic tube under the skin to connect artery and vein Arthroplasty Joint repair - to relieve pain, or restructure a joint Relevant FHx -HTN, DM, CA - MI/CAD with age of onset less than 55 y/o -PE, asthma -Crohns, IBS -CVA, aneurysm, seizures -sickle cell anemia, DVT Social History of note -tobacco use -alcohol use -illicit drug use -occupation -living circumstances Pediatric social history of note -caretaker (mother, father, grandparent) -attends daycare -attends school -has brothers/sisters -second hand smoke exposure -immunizations up to date