Subjective vs. objective: - ANSWERSFeeling vs. fact
Pain vs. tenderness - ANSWERSPatient's feeling vs. physician's assessment
Benign - ANSWERSNormal, nothing of concern
Acute vs. chronic - ANSWERSNew onset vs. long standing
Baseline - ANSWERSAn individual's normal state of being
Auscultation - ANSWERSListening with a stethoscope
Palpation - ANSWERSThe act of pressing on an area (by the physician)
Inpatient - ANSWERSAdmitted to the hospital overnight
Outpatient - ANSWERSSeen and sent home the same day
Chief complaint - ANSWERSThe main reason for the patient's visit
Mid-Level Provider - ANSWERSNurse Practitioner (LNP) or Physician Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - ANSWERSRecords medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers medications,
assists with procedures
Receptionist - ANSWERSAnswers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - ANSWERSDocuments the patient's visit on behalf of the physician
Scribes CAN.... - ANSWERS-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
Scribes CANNOT... - ANSWERS-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
, NEW Patient - ANSWERSNo previous records, Longer visit, and Detailed chart
ESTABLISHED Patient - ANSWERSPrevious records available, Shorter visit, and
Concise chart
Diagnostic Visit - ANSWERSNew problem, Chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
Health Management Visit - ANSWERSCheck-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 - ANSWERSCheck in -> Physical evaluation -> Orders & Results ->
Assessment & Plan -> Check Out
CLINIC FLOW - CHECK-IN - ANSWERSPatient 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)
CLINIC FLOW - PHYSICIAN EVAL - ANSWERSReview the patient's medical records
(Assessment & plan from the previous visit, Labs and/or imaging results) -> History and
Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical
Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the
symptoms)
CLINIC FLOW - ORDERS & RESULTS - ANSWERSOrders (Laboratory studies,
Imaging studies, and Procedures) -> Results (May result during visit (rare) or in a few
days)
CLINIC FLOW - ASSESSMENT & PLAN - ANSWERSAssessment (The list of
diagnoses) -> Plan (Follow-up with specialist if necessary, Instructions for lifestyle and
preventative care, and Follow-up for next routine appointment)
CLINIC FLOW - CHECK-OUT - ANSWERSCheck-out (Home vs. sent to the ED, Patient
education provided, and Patient will often stop at the front desk on the way out to
schedule next appointment)
SECTIONS OF A CHART - ANSWERSS (Subjective), O (Objective), A (assessment),
and P (Plan)
Patient complaint - ANSWERSHPI or ROS
Past diagnosis or surgery - ANSWERSPast History
Pain vs. tenderness - ANSWERSPatient's feeling vs. physician's assessment
Benign - ANSWERSNormal, nothing of concern
Acute vs. chronic - ANSWERSNew onset vs. long standing
Baseline - ANSWERSAn individual's normal state of being
Auscultation - ANSWERSListening with a stethoscope
Palpation - ANSWERSThe act of pressing on an area (by the physician)
Inpatient - ANSWERSAdmitted to the hospital overnight
Outpatient - ANSWERSSeen and sent home the same day
Chief complaint - ANSWERSThe main reason for the patient's visit
Mid-Level Provider - ANSWERSNurse Practitioner (LNP) or Physician Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - ANSWERSRecords medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers medications,
assists with procedures
Receptionist - ANSWERSAnswers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - ANSWERSDocuments the patient's visit on behalf of the physician
Scribes CAN.... - ANSWERS-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
Scribes CANNOT... - ANSWERS-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
, NEW Patient - ANSWERSNo previous records, Longer visit, and Detailed chart
ESTABLISHED Patient - ANSWERSPrevious records available, Shorter visit, and
Concise chart
Diagnostic Visit - ANSWERSNew problem, Chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
Health Management Visit - ANSWERSCheck-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 - ANSWERSCheck in -> Physical evaluation -> Orders & Results ->
Assessment & Plan -> Check Out
CLINIC FLOW - CHECK-IN - ANSWERSPatient 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)
CLINIC FLOW - PHYSICIAN EVAL - ANSWERSReview the patient's medical records
(Assessment & plan from the previous visit, Labs and/or imaging results) -> History and
Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical
Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the
symptoms)
CLINIC FLOW - ORDERS & RESULTS - ANSWERSOrders (Laboratory studies,
Imaging studies, and Procedures) -> Results (May result during visit (rare) or in a few
days)
CLINIC FLOW - ASSESSMENT & PLAN - ANSWERSAssessment (The list of
diagnoses) -> Plan (Follow-up with specialist if necessary, Instructions for lifestyle and
preventative care, and Follow-up for next routine appointment)
CLINIC FLOW - CHECK-OUT - ANSWERSCheck-out (Home vs. sent to the ED, Patient
education provided, and Patient will often stop at the front desk on the way out to
schedule next appointment)
SECTIONS OF A CHART - ANSWERSS (Subjective), O (Objective), A (assessment),
and P (Plan)
Patient complaint - ANSWERSHPI or ROS
Past diagnosis or surgery - ANSWERSPast History
