ScribeAmerica Outpatient Final: Practice Questions

What will the scribe document for the outpatient visit? - answer-Important notes for past medical records History and Physical Laboratory and radiology results Physician Interpretation of XRs and EKGs Assessment and Plan Who is the first person to speak with the patient after he/she is placed in the room? - answer-Nurse or MA What are the meaningful use requirements the nurse or MA will obtain? - answer-Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status What does H&P abbreviate and who performs this evaluation? - answer-History and Physical, physician Is a differential diagnosis necessary for a health maintenance visit? - answer-No, only for a diagnostic visit What information will be included in the patient's plan? - answer-Specialist follow-up, instructions for lifestyle and preventative care, routine follow-up The CBC shows anemia - answer-Results The EKG shows NSR - answer-Results The pt came to the clinic for chest pain - answer-HPI/ROS The pt also stubbed his toe last week - answer-HPI/ROS The pt is in no acute distress - answer-Physical Exam The pt has suffered from HTN for many years - answer-PMHx Thee is tenderness of the RUQ - answer-PE The pt's mother has heart disease - answer-FHX The diagnosis is upper respiratory infection - answer-Assessment The pt will be prescribed penicillin today - answer-Plan What age would a family member's cardiac disease indicate an increased risk for similar heart disease in the pt? - answer-<55 y/o What are three common general FHx your physician may ask about? - answer-HTN, CA, DM Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - answer-Yes Why must smoking status be documented on every patient 13 years and older? - answ