City MD Scribe Exam Solved 100% Correct!!

Phase 1 - ✔✔ 1.assign 2.verify & vitals 3.Past medical History 4.Chief complaint 5.HIP (history of present illness) 6.ROS (review of systems) Rapid strep - ✔✔ Sore throat rapid flu - ✔✔ flu like symptoms Urine test - ✔✔ Urine complaints, abdominal compla ints (if female) Visual acuity - ✔✔ eye complaints Past medical history (in order) - ✔✔ 1. current medication 2.Medical conditions 3.Allergies 4.Surgical history 5. family history 6. social history HPI (in order) - ✔✔ Onset severity nature Pertinent findings ROS (established vs. complex vs. New) - ✔✔ Established pt. 3 systems New PT. gets 10 systems Complex case: 10 systems Phase 2 - ✔✔ 1) present the case 2)update the HPI 3)physical exam 4) procedures 5)Assessment 6) Post diagnostic orde rs 7)Treatment (Rx) 8) preventative medicine What to show and ask the provider - ✔✔ -assessment -prescriptions -possible drug interactions -treatment -post diagnostic orders -referrals -ENM code if you are unsure Phase 3 - ✔✔ 1) Other procedures (if y ou need to contact other team members 2) Billing code 3)Send Rx 4)Discharge Stat orders (who to inform) - ✔✔ Stat lab - MA and manager