Scribe America OP Training Final exam 2023 with 100% correct answers

Scribes CAN -document the history, physical exam, results, procedures, and physician consults -access and document laboratory results and radiology findings -access and display X-rays for the physician to review -locate and obtain PMHx, previous charts, past results, and recent studies -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 Feeling Objective Factual finding from the provider Pain Patient's feeling or discomfort Tenderness Doctor's finding of reproducible pain Acute New onset, likely concerning Chronic Long-standing, not of direct concern New Patient A patient that has never been seen at the clinic, or was seen greater than 3 years ago No previous records Longer visit Detailed chart Established Patient A patient that has been seen at the clinic (by any provider) within the last 3 years Previous records available Shorter visit Concise chart Diagnostic Visit New problem Chief complaint (CC): new symptom Goal is to determine the cause of the problem and appropriate treatment