Medical Scribe Study guides, Class notes & Summaries

Vital signs - correct answer a series of measures that give an overview of a patient's overall health; heart rate, respiratory rate, blood pressure, body temperature, oxygen saturation Heart rate - correct answer the rate that your heart is pumping blood (beats per minute) (normal: 60-100 bpm) Respiratory rate - correct answer rate of someone's breathing (breaths per minute) (normal: 12-20 breaths per minute) Blood pressure - correct answer the pressure at which blood is being pumped ...

CAD - coronary artery disease HTN - hypertension DM - diabetes mellitus MI - myocardial infarction CHF - congestive heart failure AFIB - atrial fibrillation PE - pulmonary embolism DVT - deep venous thrombosis BKA - below knee amputation PTX - pneumothorax COPD - chronic obstructive pulmonary disease Acute blockage of an artery that provides blood to the brain - CVA Translocation of a thrombus leading to dyspnea and hypoxia - PE Inflammation of...

Components of MSK exam - Gait Posture Range of motion Muscle strength Specific exams (knee, shoulders, back) Range of muscle strength - Patella Tests - Patellar grinding Patellar tracking ACL tests - anterior drawer, Lachmans PCL tests - posterior drawer, posterior sag sign MCL tests - Valgus stress test LCL tests - varus stress test Meniscus tests - McMurray's & Apley's grinding Rotator cuff tests - Empty Can / Open Can Lift off sign Drop Arm Test ...

Components of MSK exam - Gait Posture Range of motion Muscle strength Specific exams (knee, shoulders, back) Range of muscle strength - Patella Tests - Patellar grinding Patellar tracking ACL tests - anterior drawer, Lachmans PCL tests - posterior drawer, posterior sag sign MCL tests - Valgus stress test LCL tests - varus stress test Meniscus tests - McMurray's & Apley's grinding Rotator cuff tests - Empty Can / Open Can Lift off sign Drop Arm Test ...

Scribes can infer patients have severe abdominal tenderness because the patient complains of 10/10 abdominal pain - False A patient presents complaining of abdominal pain. You write in the HPI that the patient complains of abdominal pain and also note this in the ROS. Your physician tells you that the abdomen is non-tender. This is a contradiction. - False What are the 5 vital signs? - HR, BP, spo2, RR, Temp Which of the following is the correct meaning of the abbreviation HIPAA - H...

What is a medical note? - The medical note is a document comprised of information regarding a patient's encounter. This document serves as the legal documentation in court for a provider and is responsible for provider's compensation based on the treatment provided to the patient. A scribe's primary job function is to assist the provider in completing the medical note with accuracy and in a timely manner. How is the medical note constructed? - The medical note is created using the SOAP m...

Scribes help physicians ensure and improve (5) - Pt care and satisfaction Depth and accuracy of documentation Insurance compensation Legal protection Pt throughout (pt seen per shift) What are scribe connect core values? (6) - Service excellence Collaboration Reliability Integrity Balance Efficiency What is a scribe? - An unlicensed individual hired to enter info into the EHR or chart at the direction of a physician or licensed independent practitioner What is SOAP - ...

Who makes the schedule - lead scribe Scribe role - trained documentation experts, assist the physician, generate charts and medical records, work directly with physicians and medical staff Medical scribes are trained documentation experts - true Company Values As a scribe you - begin on time, bring a positive attitude, respect the provider, work efficiently, communicate proactively One benefit of being a medical scribe is the opportunity to develop clinical skills - false Me...

Abrasion - superficial wound to the top most layer of the skin (scratch) Afebrile - without fever Ambulation - to walk Analgesics - pain medications Antiemetics - nausea medication Antipyretics - fever reducing medication Apnea - without breath Atelectasis - collapse of the alveoli in the lungs Avulsion - forcible tearing away of skin from the body Bradycardia - slow heart rate (under 60 bpm) Cerumen - earwax Cholecystectomy - surgical removal of the ...

Vital signs - a series of measures that give an overview of a patient's overall health; heart rate, respiratory rate, blood pressure, body temperature, oxygen saturation Heart rate - the rate that your heart is pumping blood (beats per minute) (normal: 60-100 bpm) Respiratory rate - rate of someone's breathing (breaths per minute) (normal: 12-20 breaths per minute) Blood pressure - the pressure at which blood is being pumped throughout your body (normal 90/60-140/90) (systolic ove...