ScribeAmerica Outpatient Course 1 Questions With Complete Answers.

Subjective vs. objective: - Feeling vs. fact Pain vs. tenderness - Patient's feeling vs. physician's assessment Benign - Normal, nothing of concern Acute - New onset, likely concerning Chronic - Long-standing, not of direct concern Baseline - An individual's normal state of being Auscultation - Listening with a stethoscope Palpation - The act of pressing on an area (by the physician) Inpatient - Admitted to the hospital overnight Outpatient - Seen and sent home the same day Chief complaint - The main reason for the patient's visit Mid-Level Provider - Nurse Practitioner (LNP) or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients Medical provider - Mid-level provider that diagnoses and treats patientsNurse or Medical Assistant - Records medical histories and symptoms, monitors the patient, completes the meaningful use requirements, administers medications, assists with procedures Clinical provider - Includes both the mid-level provider and nurse or medical assistant that are direct patient care Scribe - Documents the patient's visit on behalf of the physician Clerical - Receptionist and scribe that there is no patient care and only documentation Scribes CAN.... - -Document the history, physical exam, results, procedures, assessment, and plan -Access and document laboratory results and radiology findings -Locate and obtain PMHx, previous charts, past results, and recent studies -Record physician interpretations of x-rays and EKGs Assessment vs Plan - Diagnosis vs Treatment Scribes CANNOT... - -Partake in any activity that may affect patient health or outcome -Touch patients -Handle bodily fluids or specimens -Sign or authenticate any chart or record -Give verbal orders or submit electronic orders -NO direct patient care, No patient samples, No using logins other than your own NEW Patient - No previous records, Longer visit, and Detailed chart ESTABLISHED Patient - Previous records available, Shorter visit, and Concise chartDiagnostic Visit - New problem, Chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment Health Management Visit - Check-up, Chief Complaint: Routine physical or management of chronic problem(s), and Goal is preventative care and/or assessing progress of ongoing medical problems CLINIC FLOW - Check in -> Physical evaluation -> Orders & Results -> Assessment & Plan -> Check Out CLINIC FLOW - CHECK-IN - Patient Walks in (Diagnostic vs. Health Management) -> Room Placement -> Meaningful Use obtained by Nurse/MA (Chief complaint, Vital signs: HR, BP, T, RR), Height, Weight, BMI, Smoking Status) -> Nurse/MA Assessment (Confirm chief complaints, review allergies/medications , brief past medical history)