ScribeAmerica OP Final Exam 2026 UPDATE
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Terms in this set (231)
New Patient No previous records, longer visit, detailed chart
established patient Previous records available from last 3 years,
shorter visit, concise chart
Diagnostic visit New problem, chief complaint: new symptom,
goal is to determine the cause of the problem
and appropriate treatment
health management check up, CC: routine physical or management of
chronic problems, goal is preventative care
and/or assessing progress of ongoing medical
problems
Clinic Flow 1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
,Quality Measures chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and HPI, ROS, PE
Physical (H&P)
DDx differential diagnosis
Patient says high blood pressure Hypertension (HTN)
Patient says high cholesterol Hyperlipidemia (HLD)
Patient says thyroid problem Usually Hypothyroidism, sometimes
Hyperthyroidism
Patient says diabetes Diabetes Mellitus (DM)
Patient says "I only take pills for my Non-Insulin Dependent Diabetes Mellitus
diabetes" (NIDDM)
Patient says "I take shots for my Insulin Dependent Diabetes Mellitus (IDDM)
diabetes"
Patient says heart disease Coronary Artery Disease (CAD)
Patient says heart attack Myocardial Infarction (MI) and CAD
Patient says heart failure Congestive Heart Failure (CHF)
Patient says Irregular heartbeat arrhythmia
Patient says murmur heart murmur
, Patient says episodes of abnormally supraventricular tachycardia (SVT)
fast/racing heartbeat
Patient says asthma asthma
Patient says Emphysema/Chronic Chronic Obstructive Pulmonary Disease (COPD)
Bronchitis
Patient says blood clot in lung Pulmonary Embolism (PE)
Patient says pneumonia Pneumonia (PNA)
Patient says reflux Gastroesophageal Reflux Disease (GERD)
Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis pancreatitis
Patient says hepatitis Hepatitis A, B, or C
Patient says diverticulitis Diverticulitis
Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel Irritable Bowel Syndrome (IBS)
Patient says bladder infection Urinary Tract Infection (UTI)
Patient says kidney infection Pyelonephritis (Pyelo)
Patient says kidney stones renal calculi
Patient says I'm on dialysis Chronic Renal Failure (CRF) or End Stage Renal
Disease (ESRD) on dialysis
Verified Questions And Answers | With 100%
Correct Answers graded A+ Guaranteed
Success!!
Save
Terms in this set (231)
New Patient No previous records, longer visit, detailed chart
established patient Previous records available from last 3 years,
shorter visit, concise chart
Diagnostic visit New problem, chief complaint: new symptom,
goal is to determine the cause of the problem
and appropriate treatment
health management check up, CC: routine physical or management of
chronic problems, goal is preventative care
and/or assessing progress of ongoing medical
problems
Clinic Flow 1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
,Quality Measures chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and HPI, ROS, PE
Physical (H&P)
DDx differential diagnosis
Patient says high blood pressure Hypertension (HTN)
Patient says high cholesterol Hyperlipidemia (HLD)
Patient says thyroid problem Usually Hypothyroidism, sometimes
Hyperthyroidism
Patient says diabetes Diabetes Mellitus (DM)
Patient says "I only take pills for my Non-Insulin Dependent Diabetes Mellitus
diabetes" (NIDDM)
Patient says "I take shots for my Insulin Dependent Diabetes Mellitus (IDDM)
diabetes"
Patient says heart disease Coronary Artery Disease (CAD)
Patient says heart attack Myocardial Infarction (MI) and CAD
Patient says heart failure Congestive Heart Failure (CHF)
Patient says Irregular heartbeat arrhythmia
Patient says murmur heart murmur
, Patient says episodes of abnormally supraventricular tachycardia (SVT)
fast/racing heartbeat
Patient says asthma asthma
Patient says Emphysema/Chronic Chronic Obstructive Pulmonary Disease (COPD)
Bronchitis
Patient says blood clot in lung Pulmonary Embolism (PE)
Patient says pneumonia Pneumonia (PNA)
Patient says reflux Gastroesophageal Reflux Disease (GERD)
Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis pancreatitis
Patient says hepatitis Hepatitis A, B, or C
Patient says diverticulitis Diverticulitis
Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel Irritable Bowel Syndrome (IBS)
Patient says bladder infection Urinary Tract Infection (UTI)
Patient says kidney infection Pyelonephritis (Pyelo)
Patient says kidney stones renal calculi
Patient says I'm on dialysis Chronic Renal Failure (CRF) or End Stage Renal
Disease (ESRD) on dialysis
