SCRIBE FINAL EXAM GUIDE Q&A
BID - Answer-twice a day
HTN - Answer-hypertension
Pt - Answer-patient
ROS - Answer-review of systems
CXR - Answer-chest x-ray
CAD - Answer-coronary artery disease
TID - Answer-three times a day
NVD - Answer-nausea, vomiting, diarrhea
SOB - Answer-shortness of breath
US - Answer-ultrasound
CP - Answer-cerebral palsy
HPI - Answer-history of present illness
s/p - Answer-status post
HLD - Answer-hyperlipidemia (high cholesterol)
T/F Physician assistants and nurse practitioners are considered medical providers. -
Answer-T
T/F The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under supervision of the physician. - Answer-F
What will the scribe document for the outpatient visit? - Answer-- important notes for
past medical records.
- history and physical
- lab and radiology results
- physician interpretation of xrs and ekg
- assessment
- plan
, A patient made an appointment because she developed a rash a few days ago. Is this a
diagnostic or health management visit? - Answer-diagnostic
A patient has an appointment for management of her diabetes. Is this a diagnostic or
health management visit? - Answer-health management visit
Is a differential diagnosis necessary for a health management visit? - Answer-No
Give examples of information included in the patient's plan. - Answer-1. recommended
treatment for each diagnosis
2. prescriptions ordered today
3. studies/tests/labs/imaging order today
4. follow up with other healthcare providers
5. follow up here
In which sections of the chart do the following items belong?
The CBC shows anemia: _________________________________________
The pt came to the clinic for chest pain: ______________________________
The pt also stubbed his toe last week: _______________________________
The pt is in no acute distress: ______________________________________
The pt has had HTN for many years: ________________________________
The pt's diagnosis is CHF: ______________________________________
The pt will be prescribed penicillin today:_______________________ - Answer-1.
results
2. HPI
3. ROS
4. ROS
5. PMHx/HPI
6. Assessment
7. Plan
What are three common general family histories your physician may ask? - Answer-
general: HTN, DM
cardiac: MI/CAD if younger than 55
neurological: history of CVA (stroke)
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx of
the chart? Why or why not? - Answer-Yes.
Alcoholism is a disease and any alcohol consumption belongs in SHx.
The patient's mother states, "The daycare called me to pick up Megan and her brother
because Megan had a fever." What are three items you can document under social
history for Megan? - Answer-1. living circumstances
2. attends daycare
3. siblings
BID - Answer-twice a day
HTN - Answer-hypertension
Pt - Answer-patient
ROS - Answer-review of systems
CXR - Answer-chest x-ray
CAD - Answer-coronary artery disease
TID - Answer-three times a day
NVD - Answer-nausea, vomiting, diarrhea
SOB - Answer-shortness of breath
US - Answer-ultrasound
CP - Answer-cerebral palsy
HPI - Answer-history of present illness
s/p - Answer-status post
HLD - Answer-hyperlipidemia (high cholesterol)
T/F Physician assistants and nurse practitioners are considered medical providers. -
Answer-T
T/F The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under supervision of the physician. - Answer-F
What will the scribe document for the outpatient visit? - Answer-- important notes for
past medical records.
- history and physical
- lab and radiology results
- physician interpretation of xrs and ekg
- assessment
- plan
, A patient made an appointment because she developed a rash a few days ago. Is this a
diagnostic or health management visit? - Answer-diagnostic
A patient has an appointment for management of her diabetes. Is this a diagnostic or
health management visit? - Answer-health management visit
Is a differential diagnosis necessary for a health management visit? - Answer-No
Give examples of information included in the patient's plan. - Answer-1. recommended
treatment for each diagnosis
2. prescriptions ordered today
3. studies/tests/labs/imaging order today
4. follow up with other healthcare providers
5. follow up here
In which sections of the chart do the following items belong?
The CBC shows anemia: _________________________________________
The pt came to the clinic for chest pain: ______________________________
The pt also stubbed his toe last week: _______________________________
The pt is in no acute distress: ______________________________________
The pt has had HTN for many years: ________________________________
The pt's diagnosis is CHF: ______________________________________
The pt will be prescribed penicillin today:_______________________ - Answer-1.
results
2. HPI
3. ROS
4. ROS
5. PMHx/HPI
6. Assessment
7. Plan
What are three common general family histories your physician may ask? - Answer-
general: HTN, DM
cardiac: MI/CAD if younger than 55
neurological: history of CVA (stroke)
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx of
the chart? Why or why not? - Answer-Yes.
Alcoholism is a disease and any alcohol consumption belongs in SHx.
The patient's mother states, "The daycare called me to pick up Megan and her brother
because Megan had a fever." What are three items you can document under social
history for Megan? - Answer-1. living circumstances
2. attends daycare
3. siblings
