Study Guide for ScribeAmerica Final
100% Correct!!
Subjective - ANSWERSFeeling (patient)
Objective - ANSWERSFact (provider)
Benign - ANSWERSNormal, nothing of concern
Acute - ANSWERSNew onset
Chronic - ANSWERSLong-standing
Baseline - ANSWERSAn individual'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 overnight
Outpatient - 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
Mid level provider (MLP) - ANSWERSAdvanced Practice Provider
(APP) Nurse Practitioner (NP) or Physician Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant (MA) - ANSWERSRecords medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers medications,
assists with procedures
Receptionist - ANSWERSAnswers 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 - ANSWERSDocuments the patient's visit on behalf of the physician
, A scribe is an: - ANSWERSUnlicensed person performing documentation and other
non-clinical tasks under the direction of a healthcare provider.
Scribes CAN... - ANSWERS-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
Scribes CANNOT... - ANSWERS-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
New patients - ANSWERSNo previous records, longer visit, detailed chart
Established patients - ANSWERSPrevious records available, shorter visit, concise
chart, have been seen in the clinic within 3 years
Diagnostic Visit - ANSWERSNew problem, chief complaint is a new symptoms, the goal
is to determine the cause of the problem and the appropriate treament
Health Management Visit - ANSWERSCheck-up, chief complaint is a routine physical or
management of chronic problem(s), goal is preventative care and/or assessing progress
of ongoing medical problems.
Clinic Flow: Physician Evaluation - ANSWERSReview the patient's medical records.
A&P from the previous visit, labs and/or imaging results.
H&P includes HPI, ROS, PE.
Differential Dx (DDx) only for diagnostic visits. Possible Dx that may be causing the
symptoms.
Clinic Flow: Orders - ANSWERSLab studies, imaging studies, procedures.
Clinic Flow: Results - ANSWERSMay result during visit, or in a few days
Clinic Flow: Assessment - ANSWERSThe list of current diagnoses
Clinic Flow: Plan - ANSWERSFollow-up and treatment plan for each diagnosis
Clinic Flow: Check-out - ANSWERS-Home vs. sent to the ED
-Patient education provided
100% Correct!!
Subjective - ANSWERSFeeling (patient)
Objective - ANSWERSFact (provider)
Benign - ANSWERSNormal, nothing of concern
Acute - ANSWERSNew onset
Chronic - ANSWERSLong-standing
Baseline - ANSWERSAn individual'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 overnight
Outpatient - 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
Mid level provider (MLP) - ANSWERSAdvanced Practice Provider
(APP) Nurse Practitioner (NP) or Physician Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant (MA) - ANSWERSRecords medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers medications,
assists with procedures
Receptionist - ANSWERSAnswers 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 - ANSWERSDocuments the patient's visit on behalf of the physician
, A scribe is an: - ANSWERSUnlicensed person performing documentation and other
non-clinical tasks under the direction of a healthcare provider.
Scribes CAN... - ANSWERS-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
Scribes CANNOT... - ANSWERS-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
New patients - ANSWERSNo previous records, longer visit, detailed chart
Established patients - ANSWERSPrevious records available, shorter visit, concise
chart, have been seen in the clinic within 3 years
Diagnostic Visit - ANSWERSNew problem, chief complaint is a new symptoms, the goal
is to determine the cause of the problem and the appropriate treament
Health Management Visit - ANSWERSCheck-up, chief complaint is a routine physical or
management of chronic problem(s), goal is preventative care and/or assessing progress
of ongoing medical problems.
Clinic Flow: Physician Evaluation - ANSWERSReview the patient's medical records.
A&P from the previous visit, labs and/or imaging results.
H&P includes HPI, ROS, PE.
Differential Dx (DDx) only for diagnostic visits. Possible Dx that may be causing the
symptoms.
Clinic Flow: Orders - ANSWERSLab studies, imaging studies, procedures.
Clinic Flow: Results - ANSWERSMay result during visit, or in a few days
Clinic Flow: Assessment - ANSWERSThe list of current diagnoses
Clinic Flow: Plan - ANSWERSFollow-up and treatment plan for each diagnosis
Clinic Flow: Check-out - ANSWERS-Home vs. sent to the ED
-Patient education provided
