Scribe America Final Exam 100%
Accurate!!
Subjective - ANSWERSfeeling; based on conversation with patient
objective - ANSWERSfact; based on findings made by physician
benign - ANSWERSnothing of concern; no danger to health
acute - ANSWERSnew onset
chronic - ANSWERSlong standing
baseline - ANSWERSindividual's normal standard of being
auscultation - ANSWERSlistening with a stethoscope
palpation - ANSWERSact of pressing on an area (by the physician)
Inpatient - ANSWERSadmitted to the hospital overnight
outpatient - ANSWERSseen and sent home the same day
chief complaint - ANSWERSmain reason for the patient's visit
meaningful use - ANSWERSset of government mandated criteria that must be obtained
for every patient
medical decision making - ANSWERSthe physician's thought process
results or assessment - ANSWERSwhere in chart: "CBC shows anemia"
results or assessment - ANSWERSwhere in chart: "EKG shows NSR"
HPI - ANSWERSwhere in chart: "pt came to clinic for chest pain"
ROS - ANSWERSwhere in chart: "pt also stubbed his toe last week"
PE - ANSWERSwhere in chart: "pt is in no acute distress"
PMHx - ANSWERSwhere in chart: "pt has suffered from HTN for many years"
PE - ANSWERSwhere in chart: "there is tenderness of the RUQ"
, FHx - ANSWERSwhere in chart: "pt's mother has heart disease"
assessment - ANSWERSwhere in chart: "the diagnosis is URI"
plan - ANSWERSwhere in chart: "pt will be prescribed penicillin"
55 or younger - ANSWERSat what age would a family member's cardiac disease
indicate an increased risk for heart disease in the patient?
HTN, DM, CA - ANSWERSwhat are the three common general family histories your
physician may ask about?
yes - ANSWERSwould PMHx of chronic alcoholism belong in the SHx section as well
as the PMHx section?
meaningful use - ANSWERSwhy must smoking status be documented on every patient
13 years and older?
1. inhale 2. inject 3. oral - ANSWERSname the three most common routes of
administration of illicit drugs
comorbidity - ANSWERSsimultaneous presence of two chronic diseases or conditions
in a patient
etiology - ANSWERScause of a disease
systole - ANSWERSphase of heartbeat during which the muscle contracts, pumping
blood to the body
diastolic - ANSWERSphase of the heartbeat in which muscle is relaxed and the heart
fills with blood
diuretic - ANSWERSsubstance that promotes the production of urine
paresthesia - ANSWERSsensation of tingling or numbness
polydipsia - ANSWERSexcessive thirst
ischemia - ANSWERSloss of blood supply to tissue
anticoagulant - ANSWERSdrug that prevents blood clotting
infarct - ANSWERStissue death due to ischemia
Accurate!!
Subjective - ANSWERSfeeling; based on conversation with patient
objective - ANSWERSfact; based on findings made by physician
benign - ANSWERSnothing of concern; no danger to health
acute - ANSWERSnew onset
chronic - ANSWERSlong standing
baseline - ANSWERSindividual's normal standard of being
auscultation - ANSWERSlistening with a stethoscope
palpation - ANSWERSact of pressing on an area (by the physician)
Inpatient - ANSWERSadmitted to the hospital overnight
outpatient - ANSWERSseen and sent home the same day
chief complaint - ANSWERSmain reason for the patient's visit
meaningful use - ANSWERSset of government mandated criteria that must be obtained
for every patient
medical decision making - ANSWERSthe physician's thought process
results or assessment - ANSWERSwhere in chart: "CBC shows anemia"
results or assessment - ANSWERSwhere in chart: "EKG shows NSR"
HPI - ANSWERSwhere in chart: "pt came to clinic for chest pain"
ROS - ANSWERSwhere in chart: "pt also stubbed his toe last week"
PE - ANSWERSwhere in chart: "pt is in no acute distress"
PMHx - ANSWERSwhere in chart: "pt has suffered from HTN for many years"
PE - ANSWERSwhere in chart: "there is tenderness of the RUQ"
, FHx - ANSWERSwhere in chart: "pt's mother has heart disease"
assessment - ANSWERSwhere in chart: "the diagnosis is URI"
plan - ANSWERSwhere in chart: "pt will be prescribed penicillin"
55 or younger - ANSWERSat what age would a family member's cardiac disease
indicate an increased risk for heart disease in the patient?
HTN, DM, CA - ANSWERSwhat are the three common general family histories your
physician may ask about?
yes - ANSWERSwould PMHx of chronic alcoholism belong in the SHx section as well
as the PMHx section?
meaningful use - ANSWERSwhy must smoking status be documented on every patient
13 years and older?
1. inhale 2. inject 3. oral - ANSWERSname the three most common routes of
administration of illicit drugs
comorbidity - ANSWERSsimultaneous presence of two chronic diseases or conditions
in a patient
etiology - ANSWERScause of a disease
systole - ANSWERSphase of heartbeat during which the muscle contracts, pumping
blood to the body
diastolic - ANSWERSphase of the heartbeat in which muscle is relaxed and the heart
fills with blood
diuretic - ANSWERSsubstance that promotes the production of urine
paresthesia - ANSWERSsensation of tingling or numbness
polydipsia - ANSWERSexcessive thirst
ischemia - ANSWERSloss of blood supply to tissue
anticoagulant - ANSWERSdrug that prevents blood clotting
infarct - ANSWERStissue death due to ischemia
