ScribeAmerica, Outpatient, Lesson 1
Exam 100% Accurate!!
1.1 What is the role of each person in the clinic and the scope of scribe? Mid-Level?
Nurse/MA? Receptionist? Scribe? - ANSWERSMID-LEVEL: (PA/NP) works under the
supervision of the physician to diagnose and treat patients
NURSE/MA: records medical histories and sx; monitors the patient; completes
meaningful use requirements; administers medication; assists with procedures
RECEPTIONIST: answers phones; schedules patient appointments; answers patient
questions; provides patient with summary of visit with instructions from provider at
checkout; organizes the patients paperwork;
SCRIBE: documents the patients visit on behalf of they physician.
1.2 What is the difference between a new and established patient? - ANSWERSNEW
PATIENT: no previous records, longer visits, detailed chart (if not seen for 3 yrs or
more)
ESTABLISHED PT: previous records available, shorter visits, concise cha
1.3 How does a patient move through an outpatient clinic visit? - ANSWERScheck-in,
physician eval, orders & results, assessment and plan, check-out
1.4 How are patient visits documented? - ANSWERSusing S.O.A.P
1.5 How do scribes document past medical history? - ANSWERSin Past History-
PMedicalHx
1.6 How do scribes document past surgical history? - ANSWERSin Past History -
PSurgical Hx
1.7 How do scribes document family history? - ANSWERSin Past History - FamilyMHx
1.8 How do scribes document social history? - ANSWERSin Past History - SocialMHx
1.0 Subjective - ANSWERSfeeling (CC, HPI, ROS)
1.0 Objective - ANSWERSfact (PE)
1.0 Benign - ANSWERSnormal, nothing of concern
1.0 Acute - ANSWERSnew onset
1.0 Chronic - ANSWERSlong standing
, 1.0 Baseline - ANSWERSan individuals normal state of being
1.0 Auscultation - ANSWERSlistening with a stethoscope
1.0 Palpation - ANSWERSact of pressing on an area (by the physician)
1.0 Inpatient - ANSWERSadmitted to the hospital overnight
1.0 Chief Complaint - ANSWERSmain reason for the patients visit
1.0 Meaningful Use - ANSWERSset of government mandated criteria that must be
obtained for every patient (vitals)
1.0 Medical Decision Making - ANSWERSphysicians thought process
1.1 What can scribes do? - ANSWERSa. document the history, patient exam, results,
procedures, assessment and plan
b. access and document laboratory results and radiology findings
c. locate and obtain PMHx, previous charts, past results, and recent studies
d. record physicians interpretations of x-rays and EKG's
1.1 Are physicians assistants and nurse practitioners considered medical providers? -
ANSWERSyes
1.1. T/F: The scribe can listen to a patients heart and lungs as it is for learning purposes
and under the supervision of the physician? - ANSWERSfalse
1.2 What are the two types of clinic visits? - ANSWERSDIAGNOSTIC: new problem,
CC: new sx, goal is to determine the cause of the problem and appropriate treatment
HEALTH MAINTENANCE: check-up, CC: management of present chronic illness, goal
is to assess progress of ongoing/chronic medical problems
1.3 What does H&P abbreviate and who performs this evaluation? - ANSWERSHistory
and Physical - Physician
1.3 Is a differential diagnosis necessary for a health maintenance visit? - ANSWERSNo,
only for a diagnostic visit
1.3 What information will be included in the patients plan? Give 3 examples. -
ANSWERSa. follow-up with specialist if necessary
b. instructions for lifestyle and preventative care
c. follow-up for next routine appointment
1.5 Name 6 General PMHx - ANSWERSHTN, HLD, Hypothyroidism, DM 1&2
Exam 100% Accurate!!
1.1 What is the role of each person in the clinic and the scope of scribe? Mid-Level?
Nurse/MA? Receptionist? Scribe? - ANSWERSMID-LEVEL: (PA/NP) works under the
supervision of the physician to diagnose and treat patients
NURSE/MA: records medical histories and sx; monitors the patient; completes
meaningful use requirements; administers medication; assists with procedures
RECEPTIONIST: answers phones; schedules patient appointments; answers patient
questions; provides patient with summary of visit with instructions from provider at
checkout; organizes the patients paperwork;
SCRIBE: documents the patients visit on behalf of they physician.
1.2 What is the difference between a new and established patient? - ANSWERSNEW
PATIENT: no previous records, longer visits, detailed chart (if not seen for 3 yrs or
more)
ESTABLISHED PT: previous records available, shorter visits, concise cha
1.3 How does a patient move through an outpatient clinic visit? - ANSWERScheck-in,
physician eval, orders & results, assessment and plan, check-out
1.4 How are patient visits documented? - ANSWERSusing S.O.A.P
1.5 How do scribes document past medical history? - ANSWERSin Past History-
PMedicalHx
1.6 How do scribes document past surgical history? - ANSWERSin Past History -
PSurgical Hx
1.7 How do scribes document family history? - ANSWERSin Past History - FamilyMHx
1.8 How do scribes document social history? - ANSWERSin Past History - SocialMHx
1.0 Subjective - ANSWERSfeeling (CC, HPI, ROS)
1.0 Objective - ANSWERSfact (PE)
1.0 Benign - ANSWERSnormal, nothing of concern
1.0 Acute - ANSWERSnew onset
1.0 Chronic - ANSWERSlong standing
, 1.0 Baseline - ANSWERSan individuals normal state of being
1.0 Auscultation - ANSWERSlistening with a stethoscope
1.0 Palpation - ANSWERSact of pressing on an area (by the physician)
1.0 Inpatient - ANSWERSadmitted to the hospital overnight
1.0 Chief Complaint - ANSWERSmain reason for the patients visit
1.0 Meaningful Use - ANSWERSset of government mandated criteria that must be
obtained for every patient (vitals)
1.0 Medical Decision Making - ANSWERSphysicians thought process
1.1 What can scribes do? - ANSWERSa. document the history, patient exam, results,
procedures, assessment and plan
b. access and document laboratory results and radiology findings
c. locate and obtain PMHx, previous charts, past results, and recent studies
d. record physicians interpretations of x-rays and EKG's
1.1 Are physicians assistants and nurse practitioners considered medical providers? -
ANSWERSyes
1.1. T/F: The scribe can listen to a patients heart and lungs as it is for learning purposes
and under the supervision of the physician? - ANSWERSfalse
1.2 What are the two types of clinic visits? - ANSWERSDIAGNOSTIC: new problem,
CC: new sx, goal is to determine the cause of the problem and appropriate treatment
HEALTH MAINTENANCE: check-up, CC: management of present chronic illness, goal
is to assess progress of ongoing/chronic medical problems
1.3 What does H&P abbreviate and who performs this evaluation? - ANSWERSHistory
and Physical - Physician
1.3 Is a differential diagnosis necessary for a health maintenance visit? - ANSWERSNo,
only for a diagnostic visit
1.3 What information will be included in the patients plan? Give 3 examples. -
ANSWERSa. follow-up with specialist if necessary
b. instructions for lifestyle and preventative care
c. follow-up for next routine appointment
1.5 Name 6 General PMHx - ANSWERSHTN, HLD, Hypothyroidism, DM 1&2
