SCRIBE UNIVERSITY OP FINAL EXAM
STUDY GUIDE QUESTIONS AND
ANSWERS
SOAP - Answer-Subjective, Objective, Assessment, Plan
Subjective - Answer-Based on the patient's feeling (HPI,ROS)
Objective - Answer-Factual information from provider (PE)
History of Present Illness - Answer-The story of the patient's cheif complaint
Review of Systems - Answer-Head-to-toe checklist of patient's symptoms
Intermittent - Answer-Comes and goes
Waxing and waning - Answer-Always present but changing in intensity
Modifying factor - Answer-Something that makes a symptom better or worse
Exacerbate - Answer-To make worse
Attestation - Answer-The scribe and providers sign off that the chart was prepared by a
scribe
then approved by provider
Subjective information includes... - Answer-CC, HPI, ROS
Follow up is... - Answer-not a reimbursable chief complaint
Chief complaints must be... - Answer-reimubursable!
An HPI is... - Answer-Story of symptoms and event that lef to clinic visit that is at the
beginning of the chart and summarizes the reason for the visit
Order of the chart - Answer-HPI, ROS, PE, Orders, Diagnosis
Every symptom on the HPI must also be found in the... - Answer-ROS
HPI elements include: - Answer-Onset, timing, location, quality, severity, modifying
factors, associated sx, context
Onset - Answer-When did the complaint begin?
, Timing - Answer-Has it been constant, intermittent, or waxing and waning?
Location - Answer-Where is the discomfort?
Quality - Answer-Does it feel sharp, dull, aching, cramping...?
Severity - Answer-How bad is it? Mild, moderate, severe or 0-10
Modifying Factors - Answer-What makes it better? What makes it worse?
Associated Sx - Answer-Do any other symptoms accompany the complaint?
Context - Answer-Is there anything else that's important?
Is the CC an element? - Answer-NO
Single complaint formula is best for... - Answer-patients with only 1-2 complaints that
have not been previously evaluated
Single complaint formula format: - Answer-1. age and sex of the patient
2. complaint and onset
3. quality, timing, and location
4. modifying factors
5. list associated symptoms and pertinent negatives
6. describe any other important context
Multiple complaint formula is best for... - Answer-Patients who have:
1. multiple complaints
2. routine follow-up for chronic illness
3. different treatment plans for different complaints
Multiple complaint formula format: - Answer-1. introduction
2. paragragh 1 (condition 1)
3. paragragh 2 (condition 2)
4. paragragh 3 (condition 3)
5. paragragh 4 (condition 4)
Chronologic structure is best for... - Answer-Patient with complex stories:
1. patients with multiple comorbidities
2. patients who have had a significant workup in the past
3. established patients here for follow up of a chronic illness
Chronologic structure format: - Answer-1. Age and sex
2. Relevent PMHx
3. Previous evaluation
STUDY GUIDE QUESTIONS AND
ANSWERS
SOAP - Answer-Subjective, Objective, Assessment, Plan
Subjective - Answer-Based on the patient's feeling (HPI,ROS)
Objective - Answer-Factual information from provider (PE)
History of Present Illness - Answer-The story of the patient's cheif complaint
Review of Systems - Answer-Head-to-toe checklist of patient's symptoms
Intermittent - Answer-Comes and goes
Waxing and waning - Answer-Always present but changing in intensity
Modifying factor - Answer-Something that makes a symptom better or worse
Exacerbate - Answer-To make worse
Attestation - Answer-The scribe and providers sign off that the chart was prepared by a
scribe
then approved by provider
Subjective information includes... - Answer-CC, HPI, ROS
Follow up is... - Answer-not a reimbursable chief complaint
Chief complaints must be... - Answer-reimubursable!
An HPI is... - Answer-Story of symptoms and event that lef to clinic visit that is at the
beginning of the chart and summarizes the reason for the visit
Order of the chart - Answer-HPI, ROS, PE, Orders, Diagnosis
Every symptom on the HPI must also be found in the... - Answer-ROS
HPI elements include: - Answer-Onset, timing, location, quality, severity, modifying
factors, associated sx, context
Onset - Answer-When did the complaint begin?
, Timing - Answer-Has it been constant, intermittent, or waxing and waning?
Location - Answer-Where is the discomfort?
Quality - Answer-Does it feel sharp, dull, aching, cramping...?
Severity - Answer-How bad is it? Mild, moderate, severe or 0-10
Modifying Factors - Answer-What makes it better? What makes it worse?
Associated Sx - Answer-Do any other symptoms accompany the complaint?
Context - Answer-Is there anything else that's important?
Is the CC an element? - Answer-NO
Single complaint formula is best for... - Answer-patients with only 1-2 complaints that
have not been previously evaluated
Single complaint formula format: - Answer-1. age and sex of the patient
2. complaint and onset
3. quality, timing, and location
4. modifying factors
5. list associated symptoms and pertinent negatives
6. describe any other important context
Multiple complaint formula is best for... - Answer-Patients who have:
1. multiple complaints
2. routine follow-up for chronic illness
3. different treatment plans for different complaints
Multiple complaint formula format: - Answer-1. introduction
2. paragragh 1 (condition 1)
3. paragragh 2 (condition 2)
4. paragragh 3 (condition 3)
5. paragragh 4 (condition 4)
Chronologic structure is best for... - Answer-Patient with complex stories:
1. patients with multiple comorbidities
2. patients who have had a significant workup in the past
3. established patients here for follow up of a chronic illness
Chronologic structure format: - Answer-1. Age and sex
2. Relevent PMHx
3. Previous evaluation
