ScribeAmerica Study guides, Class notes & Summaries

* What medical term describes the surgical removal of the gallbladder? cholecystectomy What does "PHI" stand for? Expand the abbreviation. Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? craniotomy A patient's PCP is on vacation. The patient is scheduled t...

SCRIBEAMERICA FINAL EXAM

Which section of the chart would you find AKA? - correct answer PSHx CBC - correct answer complete blood count DP pulse - correct answer dorsalis pedis pulse S/p - correct answer status post AAA - correct answer abdominal aortic aneurysm DOE - correct answer dyspnea on exertion PNA - correct answer pneumonia IDDM - correct answer insulin dependent diabetes mellitus TIA - correct answer transient ischemic attack COPD - correct answer chronic obstructive pulmonary diseas...

What are the necessary elements to include in the HPI, ROS, PMH/FH/SH, and PE to qualify for level 5 billing? - correct answer HPI: 4 elements ROS: 10 systems PMH/FH/SH: 2 of 3 PE: 8 systems (excluding head and neck) what is medical decision making? - correct answer the physician's thought process (MDM) benign (def) - correct answer nothing of concern febrile (def) - correct answer the state of having a fever, concerning for infection acute (def) - correct answer new onset, likel...

What lab order contains the H&H? - correct answer CBC What is the difference between a BMP? - correct answer Basal Metabolic Panel - contains electrolytes, kidney function, and glucose levels; What part of the CBC does a "Differential" further characterize, RBC or WBC? - correct answer WBC What does Creatinine measure? - correct answer Renal function What is a high potassium level called? - correct answer Hyperkalemia What is a CMP - correct answer Comprehensive Metabolic Panel ...

How would you diagnose Hemmorrhagic CVA? - correct answer LP or Head CT Which of the following lab results need to be monitored closely for efficiency? - correct answer D-Dimer Troponin Creatinine (from BMP) Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? - correct answer CBC, BMP, Troponin, EKG, CXR What procedure would be used to diagnose Meningitis? Expand the abbreviation. - correct answer Lumbar Puncture Which of the following w...

A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? - correct answer acute urinary tract infection in pregnancy, 2nd trimester A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact....

SCRIBEAMERICA ED FINAL EXAM 2024

Chief Complaint - correct answer the main reason for the pt's ED visit pain vs tenderness - correct answer pt's feelings (subjective) vs physician's assessment (objective) distress - correct answer the doctor's judgement of discomfort baseline - correct answer an individual's normal state of being What CAN scribes do? - correct answer -Document Hx, PE, results, procedures, and physician consults -Access and document lab results and radiology findings -Locate and obtains PMHx, ...

A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? - correct answer acute urinary tract infection in pregnancy, 2nd trimester A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact....