Medical Scribe Final (Course 3) Questions With Correct Answers!!

Subjective - Based on pt's feelings Objective - Factual info from provider HPI - History of Present Illness History of Present Illness -Story of pt's chief complaint ROS - Review of Systems Review of Systems - Head to toe checklist of pt's symptoms Intermittent - Comes and goes (0-100) Waxing & waning - Always present but changes in intensity Modifying Factor - Something that makes a symptom better or worse Exacerbate - To make worse SOAP Note Structure - - Follows clinic flow - Subjective, Objective, Assessment, Plan Where Subjective Info Comes From - - Patient - Parent in peds patients - Child in elderly patientsWhat's Included in Subjective Section - Chief complaint, HPI, ROS Chief Complaint - - Primary reason that brought them to the clinic - ALWAYS include it Chief Complain Billing - - Every level of billing requires a CC to be reimbursed