ScribeAmerica outpatient FINAL EXAM
1(100% Verified)
Subjective - ANSWERSFeeling, pain, CC, HPI, ROS
Objective - ANSWERSFact, tenderness, PE, results
pain - ANSWERSpt's feeling
tenderness - ANSWERSphysician assessment
benign - ANSWERSnormal, nothing of concern
acute - ANSWERSnew onset
chronic - ANSWERSlong-standing; more than 3 months
auscultation - ANSWERSlistening with stethoscope
palpation - ANSWERSpressing on an area (physician)
inpatient - ANSWERSadmitted to hospital overnight
outpatient - ANSWERSseen and sent home same day
chief complaint - ANSWERSmain reason for pt's visit. Must be in HPI.
meaningful use - ANSWERSgovernment mandated criteria, must be obtained for every
patient. Smoking status, vitals (HR, BP, T, RR), height, weight, BMI.
medical decision making - ANSWERSphysician's thought process: r/o, worst first
mid-level provider - ANSWERSnurse practitioner, physician assistant, do Dx and Tx
under supervision of physician
nurse or medical assistant - ANSWERSrecord Hx, Sx, monitor pt, meaningful use, gives
meds, assists with procedures
scribe - ANSWERSclerical, not clinical. Can clean if no fluids. Cannot touch pt ever.
scribes CAN - ANSWERSdocument, access and document lab results and radiology,
locate and obtain PMHx, previous charts, past results, recent studies, record physician
interpretations of tests (X-rays, EKGs)
, scribes CANNOT - ANSWERSaffect pt health, touch pt, handle bodily fluids or
specimens, sign or authenticate a chart or record, give verbal orders, submit electronic
orders
new pt - ANSWERSlonger visit, detailed chart, new if not seen in 3 years
established pt - ANSWERSshorter visit, previous records, concise chart, established if
new to provider but not new to clinic/group
diagnostic, health maintenance - ANSWERStypes of clinic visits
clinic flow - ANSWERScheck-in, physician evaluation, orders and results, assessment
and plan, check-out
check-in - ANSWERSmeaningful use by nurse, nurse assessment (confirm CC, review
allergies/meds, brief PMHx). Changes in meds would go in HPI.
physician eval - ANSWERSreview assessment and plan from last visit, labs and
imaging results, H&P (HPI, ROS, PE), differential Dx if diagnostic visit
orders and results - ANSWERSlab studies, imaging studies, procedures (only document
these if done by physician).
assessment and plan - ANSWERSlist of Dx; follow-up with specialist, preventative care,
next for next appointment
check-out - ANSWERShome vs ED; pt education provided; schedule follow-up
CC exs - ANSWERSpt came to clinic for CP; pt has suffered from HTN for many years
ROS exs - ANSWERSpt also stubbed his toe last week
PHx exs - ANSWERSPMHx, PSHx, Sx, Fx. The pt's mother has heart disease. Would
go in HPI as well if pt mentions it as part of reason for visit.
PE exs - ANSWERSpt is in no acute distress; tenderness of the RUQ
results exs - ANSWERSCBC shows anemia; EKG shows Normal Sinus Rhythm
assessment and plan exs - ANSWERSCBC shows anemia; Dx is URI; pt will be
prescribed penicillin today
medical allergy - ANSWERSrash, itching, swelling, difficulty breathing
1(100% Verified)
Subjective - ANSWERSFeeling, pain, CC, HPI, ROS
Objective - ANSWERSFact, tenderness, PE, results
pain - ANSWERSpt's feeling
tenderness - ANSWERSphysician assessment
benign - ANSWERSnormal, nothing of concern
acute - ANSWERSnew onset
chronic - ANSWERSlong-standing; more than 3 months
auscultation - ANSWERSlistening with stethoscope
palpation - ANSWERSpressing on an area (physician)
inpatient - ANSWERSadmitted to hospital overnight
outpatient - ANSWERSseen and sent home same day
chief complaint - ANSWERSmain reason for pt's visit. Must be in HPI.
meaningful use - ANSWERSgovernment mandated criteria, must be obtained for every
patient. Smoking status, vitals (HR, BP, T, RR), height, weight, BMI.
medical decision making - ANSWERSphysician's thought process: r/o, worst first
mid-level provider - ANSWERSnurse practitioner, physician assistant, do Dx and Tx
under supervision of physician
nurse or medical assistant - ANSWERSrecord Hx, Sx, monitor pt, meaningful use, gives
meds, assists with procedures
scribe - ANSWERSclerical, not clinical. Can clean if no fluids. Cannot touch pt ever.
scribes CAN - ANSWERSdocument, access and document lab results and radiology,
locate and obtain PMHx, previous charts, past results, recent studies, record physician
interpretations of tests (X-rays, EKGs)
, scribes CANNOT - ANSWERSaffect pt health, touch pt, handle bodily fluids or
specimens, sign or authenticate a chart or record, give verbal orders, submit electronic
orders
new pt - ANSWERSlonger visit, detailed chart, new if not seen in 3 years
established pt - ANSWERSshorter visit, previous records, concise chart, established if
new to provider but not new to clinic/group
diagnostic, health maintenance - ANSWERStypes of clinic visits
clinic flow - ANSWERScheck-in, physician evaluation, orders and results, assessment
and plan, check-out
check-in - ANSWERSmeaningful use by nurse, nurse assessment (confirm CC, review
allergies/meds, brief PMHx). Changes in meds would go in HPI.
physician eval - ANSWERSreview assessment and plan from last visit, labs and
imaging results, H&P (HPI, ROS, PE), differential Dx if diagnostic visit
orders and results - ANSWERSlab studies, imaging studies, procedures (only document
these if done by physician).
assessment and plan - ANSWERSlist of Dx; follow-up with specialist, preventative care,
next for next appointment
check-out - ANSWERShome vs ED; pt education provided; schedule follow-up
CC exs - ANSWERSpt came to clinic for CP; pt has suffered from HTN for many years
ROS exs - ANSWERSpt also stubbed his toe last week
PHx exs - ANSWERSPMHx, PSHx, Sx, Fx. The pt's mother has heart disease. Would
go in HPI as well if pt mentions it as part of reason for visit.
PE exs - ANSWERSpt is in no acute distress; tenderness of the RUQ
results exs - ANSWERSCBC shows anemia; EKG shows Normal Sinus Rhythm
assessment and plan exs - ANSWERSCBC shows anemia; Dx is URI; pt will be
prescribed penicillin today
medical allergy - ANSWERSrash, itching, swelling, difficulty breathing
