ScribeAmerica Outpatient Final
Questions & Answers
Subjective - ANSWER from patient, HPI, ROS
Objective - ANSWER from physician, PE, Lab, imaging
Pain - ANSWER subjective from patient
Tenderness - ANSWER objective from physician
Benign - ANSWER Normal, nothing of concern
Acute - ANSWER New onset, <3 months
Chronic - ANSWER Long standing, >3 months
Baseline - ANSWER An individual's normal state of being
Auscultation - ANSWER Listening with a stethoscope (heart, lungs, abdomen)
Palpation - ANSWER The act of pressing on an area (by a physician)
Inpatient - ANSWER Admitted to the hospital overnight
Outpatient - ANSWER Seen and sent home the same day
Chief complaint - ANSWER the main reason for the patient's visit
Meaningful Use - ANSWER a set of government mandated criteria that must be
obtained for every patient: Chief Complaint, 5 vital signs, height, weight, BMI, smoking
status if >13 y/o
Medical Decision Making - ANSWER The physicians thought process
Mid-level provider - ANSWER Nurse Practitioner(LNP) or Physician 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 meaningful 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 touch patients, partake in any activity that may affect patient
health, handle bodily fluids or specimens, sign or authenticate any chart or record, give
verbal orders or submit electronic orders
Are physician assistants and nurse practitioners considered medical providers? -
ANSWER Yes, mid-level
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWER False
What will the scribe document for the outpatient visit?
Important notes for past medical records
History & Physical
Laboratory and radiology results
Physician interpretation of XRs and EKGs
Assessment
Plan - ANSWER All of the above
Types of Patients - ANSWER New and Established
New patient - ANSWER No previous record in the last 3 years, longer visit, detailed
chart
Established patient - ANSWER Previous records available from last 3 years, even if
from different physician in same building, shorter visit, concise chart
Types of Clinic visits - ANSWER Diagnostic and Health Maintenance/Management
Diagnostic visit - ANSWER acute problem, chief complaint = new symptom, goal is to
determine the cause of the problem and appropriate treatment, diagnose
Health Maintenance/Management visit - ANSWER Chronic symptom, every 3-4 months,
chief complaint = management of chronic problem, goal is to assess progress of
ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? - ANSWER
Established
,A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - ANSWER Diagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be? - ANSWER Health Maintenance/Management
Clinic Flow - ANSWER Check-in, Physician Evaluation, Orders & Results, Assessment
& Plan, Check-Out
Meaningful Use - ANSWER Chief Complaint, 5 Vital Signs, Height, Weight, BMI,
Smoking Status (>13y/o)
Vital Signs - ANSWER HR, BP, Pulse Ox, Temperature, Resp. Rate
Nurse/MA assessment - ANSWER Confirm CC, review allergies/medications, brief past
medical history
Physician Evaluation - ANSWER Review patient's medical record (a&p from last visit),
History and Physical (H&P), Differential Dx (only diagnostic)
Orders - ANSWER Lab studies, imaging, procedures,
Results - ANSWER May result during visit, probably in a few days
Assessment - ANSWER list of Dx
Plan - ANSWER Who to see, When to f/u, Instructions
Check-out - ANSWER Home or ED, education on illness provided, schedule f/u
Who is the first person to speak with the patient after he/she is placed in a room? -
ANSWER Nurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - ANSWER 5 Vital
(BP, HR, Temp, O2 sat, RR), BMI, height, weight, smoking, CC
What does H&P abbreviate and who performs this? - ANSWER History & Physical, by
the physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER No
What Information will be included in the patient's plan? - ANSWER Who to see, when to
see, and instructions
Name of doc system and online or paper? - ANSWER NextGen, online
, Sections of a chart - ANSWER S (HPI and ROS), Hx (PMHx, SHx, FHx), O(PE, Orders
and Results), A (Assessment), P (plan)
Patient complaint goes in - ANSWER HPI or ROS (if HPI, goes in ROS)
The CBC shows anemia, where does this info go? - ANSWER Results
The EKG shows Normal Sinus Rhythm, where does this info go? - ANSWER Results
The pt came to the clinic for CP, where does this info go? - ANSWER HPI and ROS
The pt came in for CP but also stubbed his toe, where does this info go? - ANSWER
ROS if not mentioned in HPI
The pt is in no acute distress, where does this info go? - ANSWER PE
The pt has suffered from HTN for many years, where does this info go? - ANSWER
PMHx
There is tenderness of the RUQ - ANSWER PE
The pt's mother has heart disease - ANSWER FHx
The diagnosis is upper respiratory infection, where does this info go? - ANSWER
Assessment
The patient will be prescribed penicillin today, where does this info go? - ANSWER Plan
Symptoms of a true allergy - ANSWER rash, itching, swelling, or difficulty breathing,
NOT adverse reactions (nausea, etc)
Patient says High blood pressure - ANSWER HTN
Patient says high cholesterol - ANSWER HLD
Patient says thyroid problem - ANSWER Hypothyroidism, sometimes hyperthyroidism
Patient says diabetes - ANSWER DM
Patient says I only take pills for diabetes - ANSWER NIDDM (type 2)
Patient says I take shots (insulin) for diabetes - ANSWER IDDM (type 1)
Patient says heart disease - ANSWER usually CAD
Patient says heart attack - ANSWER MI and CAD
Questions & Answers
Subjective - ANSWER from patient, HPI, ROS
Objective - ANSWER from physician, PE, Lab, imaging
Pain - ANSWER subjective from patient
Tenderness - ANSWER objective from physician
Benign - ANSWER Normal, nothing of concern
Acute - ANSWER New onset, <3 months
Chronic - ANSWER Long standing, >3 months
Baseline - ANSWER An individual's normal state of being
Auscultation - ANSWER Listening with a stethoscope (heart, lungs, abdomen)
Palpation - ANSWER The act of pressing on an area (by a physician)
Inpatient - ANSWER Admitted to the hospital overnight
Outpatient - ANSWER Seen and sent home the same day
Chief complaint - ANSWER the main reason for the patient's visit
Meaningful Use - ANSWER a set of government mandated criteria that must be
obtained for every patient: Chief Complaint, 5 vital signs, height, weight, BMI, smoking
status if >13 y/o
Medical Decision Making - ANSWER The physicians thought process
Mid-level provider - ANSWER Nurse Practitioner(LNP) or Physician 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 meaningful 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 touch patients, partake in any activity that may affect patient
health, handle bodily fluids or specimens, sign or authenticate any chart or record, give
verbal orders or submit electronic orders
Are physician assistants and nurse practitioners considered medical providers? -
ANSWER Yes, mid-level
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWER False
What will the scribe document for the outpatient visit?
Important notes for past medical records
History & Physical
Laboratory and radiology results
Physician interpretation of XRs and EKGs
Assessment
Plan - ANSWER All of the above
Types of Patients - ANSWER New and Established
New patient - ANSWER No previous record in the last 3 years, longer visit, detailed
chart
Established patient - ANSWER Previous records available from last 3 years, even if
from different physician in same building, shorter visit, concise chart
Types of Clinic visits - ANSWER Diagnostic and Health Maintenance/Management
Diagnostic visit - ANSWER acute problem, chief complaint = new symptom, goal is to
determine the cause of the problem and appropriate treatment, diagnose
Health Maintenance/Management visit - ANSWER Chronic symptom, every 3-4 months,
chief complaint = management of chronic problem, goal is to assess progress of
ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? - ANSWER
Established
,A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - ANSWER Diagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be? - ANSWER Health Maintenance/Management
Clinic Flow - ANSWER Check-in, Physician Evaluation, Orders & Results, Assessment
& Plan, Check-Out
Meaningful Use - ANSWER Chief Complaint, 5 Vital Signs, Height, Weight, BMI,
Smoking Status (>13y/o)
Vital Signs - ANSWER HR, BP, Pulse Ox, Temperature, Resp. Rate
Nurse/MA assessment - ANSWER Confirm CC, review allergies/medications, brief past
medical history
Physician Evaluation - ANSWER Review patient's medical record (a&p from last visit),
History and Physical (H&P), Differential Dx (only diagnostic)
Orders - ANSWER Lab studies, imaging, procedures,
Results - ANSWER May result during visit, probably in a few days
Assessment - ANSWER list of Dx
Plan - ANSWER Who to see, When to f/u, Instructions
Check-out - ANSWER Home or ED, education on illness provided, schedule f/u
Who is the first person to speak with the patient after he/she is placed in a room? -
ANSWER Nurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - ANSWER 5 Vital
(BP, HR, Temp, O2 sat, RR), BMI, height, weight, smoking, CC
What does H&P abbreviate and who performs this? - ANSWER History & Physical, by
the physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER No
What Information will be included in the patient's plan? - ANSWER Who to see, when to
see, and instructions
Name of doc system and online or paper? - ANSWER NextGen, online
, Sections of a chart - ANSWER S (HPI and ROS), Hx (PMHx, SHx, FHx), O(PE, Orders
and Results), A (Assessment), P (plan)
Patient complaint goes in - ANSWER HPI or ROS (if HPI, goes in ROS)
The CBC shows anemia, where does this info go? - ANSWER Results
The EKG shows Normal Sinus Rhythm, where does this info go? - ANSWER Results
The pt came to the clinic for CP, where does this info go? - ANSWER HPI and ROS
The pt came in for CP but also stubbed his toe, where does this info go? - ANSWER
ROS if not mentioned in HPI
The pt is in no acute distress, where does this info go? - ANSWER PE
The pt has suffered from HTN for many years, where does this info go? - ANSWER
PMHx
There is tenderness of the RUQ - ANSWER PE
The pt's mother has heart disease - ANSWER FHx
The diagnosis is upper respiratory infection, where does this info go? - ANSWER
Assessment
The patient will be prescribed penicillin today, where does this info go? - ANSWER Plan
Symptoms of a true allergy - ANSWER rash, itching, swelling, or difficulty breathing,
NOT adverse reactions (nausea, etc)
Patient says High blood pressure - ANSWER HTN
Patient says high cholesterol - ANSWER HLD
Patient says thyroid problem - ANSWER Hypothyroidism, sometimes hyperthyroidism
Patient says diabetes - ANSWER DM
Patient says I only take pills for diabetes - ANSWER NIDDM (type 2)
Patient says I take shots (insulin) for diabetes - ANSWER IDDM (type 1)
Patient says heart disease - ANSWER usually CAD
Patient says heart attack - ANSWER MI and CAD
