ScribeAmerica OP Final Exam flashcards
questions & answers( Verified 100%)
pain vs tenderness - ANSWER-patient's feeling vs physician's assessment
acute vs chronic - ANSWER-new onset vs long standing
Meaningful Use (MU) - ANSWER-a set of government mandated criteria that must be
obtained for every patient
Medical decision making - ANSWER-the physician's thought process
Mid-level providers: - ANSWER-Nurse Practitioner (LNP) or Physician's Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - ANSWER-records medical histories and symptoms,
monitors the patient, completes meaning use requirements, administers medications,
assists with procedures
Receptionist - ANSWER-answers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - ANSWER-documents the patient's visit on behalf of the physician
Scribes CANNOT... - ANSWER--partake in any activity that may affect patient health or
outcome
-touch patients
-handle bodily fluids or specimens
-sign or authenticate any chart or record
-give verbal orders or submit electronic orders
Scribes CAN... - ANSWER--document the history, physical exam, results, procedures,
assessment and plan
-access and document laboratory results and radiology findings
-locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
New patients - ANSWER--no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new
, Established patients - ANSWER--previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years
Diagnostic visit - ANSWER--new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary
Health Maintenance visit - ANSWER--check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems
allergy - ANSWER-a medication that causes a rash, itching, swelling, or difficulty
breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy
Hypertension (HTN) - ANSWER-high blood pressure
Hyperlipidemia (HLD) - ANSWER-high cholesterol
Normal heart rate - ANSWER-60-100 bpm
Pulmonary Embolism (PE) - ANSWER-blood clot in lung
Gravida/Para/Abortion - ANSWER-G - the total number of times the patient has been
pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions
Cerebrovascular Accident (CVA) - ANSWER-stroke
Transient Ischemic Attack (TIA) - ANSWER-mini-stroke
Tonsillectomy - ANSWER-tonsils removed
Adenoidectomy - ANSWER-adenoids removed
Coronary Artery Bypass Graft - ANSWER-heart bypass (PMHx CAD)
Angioplasty - ANSWER-balloon
Automatic Implanted Cardiac-Defribrillator (AICD) - ANSWER-defibrillator
Mastectomy - ANSWER-breast removal
questions & answers( Verified 100%)
pain vs tenderness - ANSWER-patient's feeling vs physician's assessment
acute vs chronic - ANSWER-new onset vs long standing
Meaningful Use (MU) - ANSWER-a set of government mandated criteria that must be
obtained for every patient
Medical decision making - ANSWER-the physician's thought process
Mid-level providers: - ANSWER-Nurse Practitioner (LNP) or Physician's Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - ANSWER-records medical histories and symptoms,
monitors the patient, completes meaning use requirements, administers medications,
assists with procedures
Receptionist - ANSWER-answers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - ANSWER-documents the patient's visit on behalf of the physician
Scribes CANNOT... - ANSWER--partake in any activity that may affect patient health or
outcome
-touch patients
-handle bodily fluids or specimens
-sign or authenticate any chart or record
-give verbal orders or submit electronic orders
Scribes CAN... - ANSWER--document the history, physical exam, results, procedures,
assessment and plan
-access and document laboratory results and radiology findings
-locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
New patients - ANSWER--no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new
, Established patients - ANSWER--previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years
Diagnostic visit - ANSWER--new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary
Health Maintenance visit - ANSWER--check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems
allergy - ANSWER-a medication that causes a rash, itching, swelling, or difficulty
breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy
Hypertension (HTN) - ANSWER-high blood pressure
Hyperlipidemia (HLD) - ANSWER-high cholesterol
Normal heart rate - ANSWER-60-100 bpm
Pulmonary Embolism (PE) - ANSWER-blood clot in lung
Gravida/Para/Abortion - ANSWER-G - the total number of times the patient has been
pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions
Cerebrovascular Accident (CVA) - ANSWER-stroke
Transient Ischemic Attack (TIA) - ANSWER-mini-stroke
Tonsillectomy - ANSWER-tonsils removed
Adenoidectomy - ANSWER-adenoids removed
Coronary Artery Bypass Graft - ANSWER-heart bypass (PMHx CAD)
Angioplasty - ANSWER-balloon
Automatic Implanted Cardiac-Defribrillator (AICD) - ANSWER-defibrillator
Mastectomy - ANSWER-breast removal
