ScribeAmerica outpatient FINAL EXAM 1
Correct 100%
Subjective - ANSWER Feeling, pain, CC, HPI, ROS
Objective - ANSWER Fact, tenderness, PE, results
pain - ANSWER pt's feeling
tenderness - ANSWER physician assessment
benign - ANSWER normal, nothing of concern
acute - ANSWER new onset
chronic - ANSWER long-standing; more than 3 months
auscultation - ANSWER listening with stethoscope
palpation - ANSWER pressing on an area (physician)
inpatient - ANSWER admitted to hospital overnight
outpatient - ANSWER seen and sent home same day
chief complaint - ANSWER main reason for pt's visit. Must be in HPI.
meaningful use - ANSWER government mandated criteria, must be obtained for every
patient. Smoking status, vitals (HR, BP, T, RR), height, weight, BMI.
medical decision making - ANSWER physician's thought process: r/o, worst first
mid-level provider - ANSWER nurse practitioner, physician assistant, do Dx and Tx
under supervision of physician
nurse or medical assistant - ANSWER record Hx, Sx, monitor pt, meaningful use, gives
meds, assists with procedures
scribe - ANSWER clerical, not clinical. Can clean if no fluids. Cannot touch pt ever.
scribes CAN - ANSWER document, access and document lab results and radiology,
locate and obtain PMHx, previous charts, past results, recent studies, record physician
interpretations of tests (X-rays, EKGs)
, scribes CANNOT - ANSWER affect pt health, touch pt, handle bodily fluids or
specimens, sign or authenticate a chart or record, give verbal orders, submit electronic
orders
new pt - ANSWER longer visit, detailed chart, new if not seen in 3 years
established pt - ANSWER shorter visit, previous records, concise chart, established if
new to provider but not new to clinic/group
diagnostic, health maintenance - ANSWER types of clinic visits
clinic flow - ANSWER check-in, physician evaluation, orders and results, assessment
and plan, check-out
check-in - ANSWER meaningful use by nurse, nurse assessment (confirm CC, review
allergies/meds, brief PMHx). Changes in meds would go in HPI.
physician eval - ANSWER review assessment and plan from last visit, labs and imaging
results, H&P (HPI, ROS, PE), differential Dx if diagnostic visit
orders and results - ANSWER lab studies, imaging studies, procedures (only document
these if done by physician).
assessment and plan - ANSWER list of Dx; follow-up with specialist, preventative care,
next for next appointment
check-out - ANSWER home vs ED; pt education provided; schedule follow-up
CC exs - ANSWER pt came to clinic for CP; pt has suffered from HTN for many years
ROS exs - ANSWER pt also stubbed his toe last week
PHx exs - ANSWER PMHx, PSHx, Sx, Fx. The pt's mother has heart disease. Would go
in HPI as well if pt mentions it as part of reason for visit.
PE exs - ANSWER pt is in no acute distress; tenderness of the RUQ
results exs - ANSWER CBC shows anemia; EKG shows Normal Sinus Rhythm
assessment and plan exs - ANSWER CBC shows anemia; Dx is URI; pt will be
prescribed penicillin today
medical allergy - ANSWER rash, itching, swelling, difficulty breathing
adverse reaction - ANSWER any unwanted reaction to a medicine that is not a true
allergy (rash, itching, swelling, dyspnea)
Correct 100%
Subjective - ANSWER Feeling, pain, CC, HPI, ROS
Objective - ANSWER Fact, tenderness, PE, results
pain - ANSWER pt's feeling
tenderness - ANSWER physician assessment
benign - ANSWER normal, nothing of concern
acute - ANSWER new onset
chronic - ANSWER long-standing; more than 3 months
auscultation - ANSWER listening with stethoscope
palpation - ANSWER pressing on an area (physician)
inpatient - ANSWER admitted to hospital overnight
outpatient - ANSWER seen and sent home same day
chief complaint - ANSWER main reason for pt's visit. Must be in HPI.
meaningful use - ANSWER government mandated criteria, must be obtained for every
patient. Smoking status, vitals (HR, BP, T, RR), height, weight, BMI.
medical decision making - ANSWER physician's thought process: r/o, worst first
mid-level provider - ANSWER nurse practitioner, physician assistant, do Dx and Tx
under supervision of physician
nurse or medical assistant - ANSWER record Hx, Sx, monitor pt, meaningful use, gives
meds, assists with procedures
scribe - ANSWER clerical, not clinical. Can clean if no fluids. Cannot touch pt ever.
scribes CAN - ANSWER document, access and document lab results and radiology,
locate and obtain PMHx, previous charts, past results, recent studies, record physician
interpretations of tests (X-rays, EKGs)
, scribes CANNOT - ANSWER affect pt health, touch pt, handle bodily fluids or
specimens, sign or authenticate a chart or record, give verbal orders, submit electronic
orders
new pt - ANSWER longer visit, detailed chart, new if not seen in 3 years
established pt - ANSWER shorter visit, previous records, concise chart, established if
new to provider but not new to clinic/group
diagnostic, health maintenance - ANSWER types of clinic visits
clinic flow - ANSWER check-in, physician evaluation, orders and results, assessment
and plan, check-out
check-in - ANSWER meaningful use by nurse, nurse assessment (confirm CC, review
allergies/meds, brief PMHx). Changes in meds would go in HPI.
physician eval - ANSWER review assessment and plan from last visit, labs and imaging
results, H&P (HPI, ROS, PE), differential Dx if diagnostic visit
orders and results - ANSWER lab studies, imaging studies, procedures (only document
these if done by physician).
assessment and plan - ANSWER list of Dx; follow-up with specialist, preventative care,
next for next appointment
check-out - ANSWER home vs ED; pt education provided; schedule follow-up
CC exs - ANSWER pt came to clinic for CP; pt has suffered from HTN for many years
ROS exs - ANSWER pt also stubbed his toe last week
PHx exs - ANSWER PMHx, PSHx, Sx, Fx. The pt's mother has heart disease. Would go
in HPI as well if pt mentions it as part of reason for visit.
PE exs - ANSWER pt is in no acute distress; tenderness of the RUQ
results exs - ANSWER CBC shows anemia; EKG shows Normal Sinus Rhythm
assessment and plan exs - ANSWER CBC shows anemia; Dx is URI; pt will be
prescribed penicillin today
medical allergy - ANSWER rash, itching, swelling, difficulty breathing
adverse reaction - ANSWER any unwanted reaction to a medicine that is not a true
allergy (rash, itching, swelling, dyspnea)
