medical scribe exam Questions With Correct Answers!!

What is the chief complaint? - ✔✔ the reason the patient is coming in to be seen by the provider; ED and outpatient What is the history of present illness? - ✔✔ this s ection is used to expand and describe the chief complaint; subjective from patient and family what is an example of HPI? - ✔✔ mary wallace is a 45 year old who comes to the ED with chest pain. her pain in sharp and radiates down her left arm. What is the Review of Systems (ROS)? - ✔✔ ROS is a systems review to reveal subjective symptoms for each body system what is constitutional ROS? - ✔✔ fever or chills what is eyes ROS? - ✔✔ blurred vision or double vision what is ent ROS? - ✔✔ sore throat, ear pain, or rhinorhhea what is respiratory ROS? - ✔✔ shortness of breath or coughing what is cardiovascular ROS? - ✔✔ chest pain and palpitations what is gastrointestinal ROS? - ✔✔ nausea, vomiting, diarrhea, or abdominal pain what is genitourinary ROS? - ✔✔ dysuria and hematuria what is musculoskeletal ROS? - ✔✔ back pain, joint pain or swelling what is integumentary ROS? - ✔✔ rash or open wounds what is neurologic ROS? - ✔✔ headache, dizziness, weakness, numbness, and ti ngling what is psychiatric ROS? - ✔✔ suicidal ideations or hallucinations what is past medical, social, and family history? - ✔✔ section to find patients medical, surgical, family, and social history physical findings: - ✔✔ section where we document what t he medical provider finds when examining the patient; objective labs: - ✔✔ often ordered to measure different substances in blood and urine, copy and past lab results into the note imaging: - ✔✔ imaging studies are order and sent to a radiologist to review the films and produce a written report, this report is pasted into the note final diagnosis or assessment: - ✔✔ section where we record the diagnoses, the diagnosis is the actual cause of patients symptoms; cough might end up with a diagnosis of pneumonia disposition ED ONLY: - ✔✔ the section of the note that will show what happens to the patient when they leave the ED chief complaint SCRATCH -MD: - ✔✔ Severity, context, region/radiation, associated symptoms, timing, character, modifying factors, duration/onset cerumen impaction removal: - ✔✔ ear wax removal by micro suction, mechanical, removal, and irrigation