City MD Scribe Latest 2024 Already Graded A

City MD Scribe Latest 2024 Already Graded A Phase 1 n y & 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 complaints (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 orders 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 you need to contact other team members 2) Billing code 3)Send Rx 4)Discharge Stat orders (who to inform) Stat lab- MA and manager Stat Advance imaging- PCR and Manager Stat Refferal- PCR and manager Stat X-ray- X-ray tec and Manager *inform them at the beginning of phase 3 Types of Forms in scribe binder Uninsured super bill (USB) Non-covered service waiver (NCS) HIV consent form HSV handout PPD reading form Against medical Advice (AMA) Occupational medicine Self-pay Super bill Physicians Procedure Consent form Symptomatic STD testing HPI 1- Primary Complaint HPI2 - STD questionnaire Asymptomatic STD testing HPI 1- STD testing/counseling HPI 2- STD questionnaire Work related injury/Workers Compensation HPI 1- Primary complaint HPI 2- Work related injury IN assessment put "Y99.0 work related injury" MVA/ No fault Insurance HPI 1-Primary complaint HPI 2- MVA -In additional diagnosis put "motor vehicle accident -should be indicated on office page Black flag A patient workup is required. Person who brought in the patient likely obtaining the vital signs but nothing else Blue flag Signal that a medical scribe is in the room. Stays up until patient is discharged yellow and Green flag Used by providers to signal which provider is in what room. stays until patient is discharged White flag procedure that could take more than 10 minutes or needs a MA/X-ray tech red flag The next room that the provider has to go into All flags and door is open The room is out of order All flags and the door is closed Do not disturb Exam chair Drawer (Front) Urine cups Speculums VCM swab BZK wipes Exam chair Drawers (Back) Elastic bandages Ice packs Nebulizer masks Gowns and Chuxs Exam chair (back flap) Nebulizer machine Counter top Rapid flu Rapid strep Pulse Ox Go-TO drawer Culture swabs Tourniquet Band-aids Medical tape Lube Cuvettes Appirm and Aptima Bacitracin Lancets Alcohol pads suture drawer Gauze patch Skin staple remover Incision and drainage kit Skin stapler splash guard ChloraPrep Sutures Cautery Pen Cabinets Top: Solutions, suture tray, IV bag Middle: Vacutainer, Butterfly needle, Syringes, IV tubing Bottom: Lidocaine, IV catheter, Tegaderm Lab Sharps container Alcohol UA strips UCG Packet UA machine Urine collection Kit