Scribe America Final Exam OP Subjective Questions And Answers.
Subjective - Patient feeling
objective - provider fact
pain - patient's feeling
tenderness - provider assessment
baseline - an individual's normal state of being
auscultation - listening with a stethoscope
palpation - the act of pressing on an area by provider
inpatient - admitted overnight
outpatient - seen and sent home the same day
chief complaint - main reason for patient's visit
meaningful use - set of gov't mandated criteria that must be obtained for every patient
medical decision making - physician's thought process
new patients - longer visit, concise chart
established patients - shorter visit, concise chart
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, diagnostic visit - visit for a new problem; CC is a new symptom; determine cause of problem and
appropriate treatment
health maintenance visit - check up; CC management of chronic problem; assess progress of
ongoing/chronic problem; preventative care
SOAP - subjective, objective, assessment, plan
subjective section - includes history of present illness, review of systems
history of present illness - story and context of chief complaint
objective evaluation - physical examination, orders and results
assessment section - diagnoses
plan section - treatment and follow up
"high blood pressure" - hypertension - HTN
"high cholesterol" - hyperlipidemia - HLD
"thyroid problem" - hypothyroidism or hyper
"I only take pills for my diabetes" - Non-Insulin dependent diabetes mellitus (NIDDM)
"I take shots for my diabetes" - Insulin dependent diabetes mellitus (IDDM)
"heart attack" - myocardial infarction - MI and CAD
"heart disease" - usually coronary artery disease - CAD
https://www.stuvia.com/
Subjective - Patient feeling
objective - provider fact
pain - patient's feeling
tenderness - provider assessment
baseline - an individual's normal state of being
auscultation - listening with a stethoscope
palpation - the act of pressing on an area by provider
inpatient - admitted overnight
outpatient - seen and sent home the same day
chief complaint - main reason for patient's visit
meaningful use - set of gov't mandated criteria that must be obtained for every patient
medical decision making - physician's thought process
new patients - longer visit, concise chart
established patients - shorter visit, concise chart
https://www.stuvia.com/
, diagnostic visit - visit for a new problem; CC is a new symptom; determine cause of problem and
appropriate treatment
health maintenance visit - check up; CC management of chronic problem; assess progress of
ongoing/chronic problem; preventative care
SOAP - subjective, objective, assessment, plan
subjective section - includes history of present illness, review of systems
history of present illness - story and context of chief complaint
objective evaluation - physical examination, orders and results
assessment section - diagnoses
plan section - treatment and follow up
"high blood pressure" - hypertension - HTN
"high cholesterol" - hyperlipidemia - HLD
"thyroid problem" - hypothyroidism or hyper
"I only take pills for my diabetes" - Non-Insulin dependent diabetes mellitus (NIDDM)
"I take shots for my diabetes" - Insulin dependent diabetes mellitus (IDDM)
"heart attack" - myocardial infarction - MI and CAD
"heart disease" - usually coronary artery disease - CAD
https://www.stuvia.com/
