ScribeAmerica Outpatient Day 1 Exam
QAS 100% Correct
Subjective vs objective: - ANSWERSFeeling (patient) vs fact (provider)
Pain vs Tenderness: - ANSWERSpatient's feeling (subjective) vs physician's
observation (objective)
Benign: - ANSWERSNormal, nothing of concern
Acute vs chronic: - ANSWERSnew onset vs long standing [does not indicate severity]
Baseline: - ANSWERSindividual's normal state of being
Auscultation: - ANSWERSlistening with a stethoscope
Palpation: - ANSWERSthe act of pressing on an area (by the physician)
Inpatient: - ANSWERSAdmitted to the hospital for an overnight
Outpatient (OP): - ANSWERSSeen and sent home the same day
Chief complaint (CC): - ANSWERSThe main reason for the patient's visit
Medical Decision Making (MDM): - ANSWERSThe physician's thought process
Receptionist - ANSWERS• Receptionist: 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 - ANSWERS• Scribe: Documents the patient's visit on behalf of the physician
What can a scribe do? - ANSWERSDocument the hisotry, physical exam, results,
procedures, assessment and plan. - access and document laboratory results and
radiology findings. - location and obtain PMHx, previous charts, past results, and recent
studies. - Record physician interpretations of x-rays and EKGs
What can't a scribe do? - ANSWERSPartake in any activity that may affect patient
health or outcome, touch patients, handle fluids or specimens, sign or authenticate any
chart or record, or give verbal orders or submit electronic orders.
What are the two types of patients? How are they different? - ANSWERSNew: No
previous records, longer visit, more detailed chart [if its been more than 3 years since
, they've visited, they're new] Established:Previous records available, shorter visit,
concise chart [must have been seen in the clinic within 3 years]\ Mid-level provider
(MLP) - ANSWERSworks under the supervision of a physician to diagnose and treat
patients. Includes Advanced practice provider (APP) Nurse Practitioner (NP) or
Physician Assistant (PA)
Nurse or Medical Assistant - ANSWERS"
Nurse or Medical Assistant (MA): Records medical - ANSWERS
histories and symptoms, monitors the patient, completes - ANSWERS
meaningful use requirements, administers medications, - ANSWERS
assists with procedures" - ANSWERS
What are the two types of clinic visits? - ANSWERSDiagnostic: New problem, chief
complaint is a new symptom, goal is to determine the cause of the problem and
appropriate treatment. Health Management: Check up, chief complain is routine
physical or management of chronic problems. Goal is preventative care and/or
assessing medical problems
What are the main categories of a patient's chart? - ANSWERSSubjective, Objective,
Assessment, and Plan
What things do you include under the subjective portion of a patient's chart? -
ANSWERSTheir experiences. Includes the HPI (chief complaint), ROS (any symptoms,
NOT DISEASE)
What things do you include under the objective portion of a patient's chart? -
ANSWERSPhysical exam (everything you do in the room), past medical history (prior
dx), labs and results
The H&P stands for what (and includes what?) - ANSWERSStands for history and PE,
includes the HPI, ROS and PE
What information would you put under the HPI of a chart? - ANSWERSSymptoms and
past Dx that relate to chief complaint
What information would you put under the ROS portion of a patient's chart? -
ANSWERSAny symptoms the patient mentions
QAS 100% Correct
Subjective vs objective: - ANSWERSFeeling (patient) vs fact (provider)
Pain vs Tenderness: - ANSWERSpatient's feeling (subjective) vs physician's
observation (objective)
Benign: - ANSWERSNormal, nothing of concern
Acute vs chronic: - ANSWERSnew onset vs long standing [does not indicate severity]
Baseline: - ANSWERSindividual's normal state of being
Auscultation: - ANSWERSlistening with a stethoscope
Palpation: - ANSWERSthe act of pressing on an area (by the physician)
Inpatient: - ANSWERSAdmitted to the hospital for an overnight
Outpatient (OP): - ANSWERSSeen and sent home the same day
Chief complaint (CC): - ANSWERSThe main reason for the patient's visit
Medical Decision Making (MDM): - ANSWERSThe physician's thought process
Receptionist - ANSWERS• Receptionist: 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 - ANSWERS• Scribe: Documents the patient's visit on behalf of the physician
What can a scribe do? - ANSWERSDocument the hisotry, physical exam, results,
procedures, assessment and plan. - access and document laboratory results and
radiology findings. - location and obtain PMHx, previous charts, past results, and recent
studies. - Record physician interpretations of x-rays and EKGs
What can't a scribe do? - ANSWERSPartake in any activity that may affect patient
health or outcome, touch patients, handle fluids or specimens, sign or authenticate any
chart or record, or give verbal orders or submit electronic orders.
What are the two types of patients? How are they different? - ANSWERSNew: No
previous records, longer visit, more detailed chart [if its been more than 3 years since
, they've visited, they're new] Established:Previous records available, shorter visit,
concise chart [must have been seen in the clinic within 3 years]\ Mid-level provider
(MLP) - ANSWERSworks under the supervision of a physician to diagnose and treat
patients. Includes Advanced practice provider (APP) Nurse Practitioner (NP) or
Physician Assistant (PA)
Nurse or Medical Assistant - ANSWERS"
Nurse or Medical Assistant (MA): Records medical - ANSWERS
histories and symptoms, monitors the patient, completes - ANSWERS
meaningful use requirements, administers medications, - ANSWERS
assists with procedures" - ANSWERS
What are the two types of clinic visits? - ANSWERSDiagnostic: New problem, chief
complaint is a new symptom, goal is to determine the cause of the problem and
appropriate treatment. Health Management: Check up, chief complain is routine
physical or management of chronic problems. Goal is preventative care and/or
assessing medical problems
What are the main categories of a patient's chart? - ANSWERSSubjective, Objective,
Assessment, and Plan
What things do you include under the subjective portion of a patient's chart? -
ANSWERSTheir experiences. Includes the HPI (chief complaint), ROS (any symptoms,
NOT DISEASE)
What things do you include under the objective portion of a patient's chart? -
ANSWERSPhysical exam (everything you do in the room), past medical history (prior
dx), labs and results
The H&P stands for what (and includes what?) - ANSWERSStands for history and PE,
includes the HPI, ROS and PE
What information would you put under the HPI of a chart? - ANSWERSSymptoms and
past Dx that relate to chief complaint
What information would you put under the ROS portion of a patient's chart? -
ANSWERSAny symptoms the patient mentions
