ScribeAmerica Outpatient Final Exam
100% Accurate!!
Subjective - ANSWERSfrom patient, HPI, ROS
Objective - ANSWERSfrom physician, PE, Lab, imaging
Pain - ANSWERSsubjective from patient
Tenderness - ANSWERSobjective from physician
Benign - ANSWERSNormal, nothing of concern
Acute - ANSWERSNew onset, <3 months
Chronic - ANSWERSLong standing, >3 months
Baseline - ANSWERSAn individual's normal state of being
Auscultation - ANSWERSListening with a stethoscope (heart, lungs, abdomen)
Palpation - ANSWERSThe act of pressing on an area (by a 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
Meaningful Use - ANSWERSa set of government mandated criteria that must be
obtained for every patient: Chief Complaint, 5 vital signs, height, weight, BMI, smoking
status if >13 y/o
Medical Decision Making - ANSWERSThe physicians thought process
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 cannot - ANSWERStouch patients, partake in any activity that may affect
patient health, handle bodily fluids or specimens, sign or authenticate any chart or
record, give verbal orders or submit electronic orders
Are physician assistants and nurse practitioners considered medical providers? -
ANSWERSYes, mid-level
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWERSFalse
What will the scribe document for the outpatient visit?
Important notes for past medical records
History & Physical
Laboratory and radiology results
Physician interpretation of XRs and EKGs
Assessment
Plan - ANSWERSAll of the above
Types of Patients - ANSWERSNew and Established
New patient - ANSWERSNo previous record in the last 3 years, longer visit, detailed
chart
Established patient - ANSWERSPrevious records available from last 3 years, even if
from different physician in same building, shorter visit, concise chart
Types of Clinic visits - ANSWERSDiagnostic and Health Maintenance/Management
Diagnostic visit - ANSWERSacute problem, chief complaint = new symptom, goal is to
determine the cause of the problem and appropriate treatment, diagnose
Health Maintenance/Management visit - ANSWERSChronic symptom, every 3-4
months, chief complaint = management of chronic problem, goal is to assess progress
of ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? -
ANSWERSEstablished
,A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - ANSWERSDiagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be? - ANSWERSHealth Maintenance/Management
Clinic Flow - ANSWERSCheck-in, Physician Evaluation, Orders & Results, Assessment
& Plan, Check-Out
Meaningful Use - ANSWERSChief Complaint, 5 Vital Signs, Height, Weight, BMI,
Smoking Status (>13y/o)
Vital Signs - ANSWERSHR, BP, Pulse Ox, Temperature, Resp. Rate
Nurse/MA assessment - ANSWERSConfirm CC, review allergies/medications, brief past
medical history
Physician Evaluation - ANSWERSReview patient's medical record (a&p from last visit),
History and Physical (H&P), Differential Dx (only diagnostic)
Orders - ANSWERSLab studies, imaging, procedures,
Results - ANSWERSMay result during visit, probably in a few days
Assessment - ANSWERSlist of Dx
Plan - ANSWERSWho to see, When to f/u, Instructions
Check-out - ANSWERSHome or ED, education on illness provided, schedule f/u
Who is the first person to speak with the patient after he/she is placed in a room? -
ANSWERSNurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - ANSWERS5
Vital (BP, HR, Temp, O2 sat, RR), BMI, height, weight, smoking, CC
What does H&P abbreviate and who performs this? - ANSWERSHistory & Physical, by
the physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWERSNo
What Information will be included in the patient's plan? - ANSWERSWho to see, when
to see, and instructions
Name of doc system and online or paper? - ANSWERSNextGen, online
, Sections of a chart - ANSWERSS (HPI and ROS), Hx (PMHx, SHx, FHx), O(PE, Orders
and Results), A (Assessment), P (plan)
Patient complaint goes in - ANSWERSHPI or ROS (if HPI, goes in ROS)
The CBC shows anemia, where does this info go? - ANSWERSResults
The EKG shows Normal Sinus Rhythm, where does this info go? - ANSWERSResults
The pt came to the clinic for CP, where does this info go? - ANSWERSHPI and ROS
The pt came in for CP but also stubbed his toe, where does this info go? -
ANSWERSROS if not mentioned in HPI
The pt is in no acute distress, where does this info go? - ANSWERSPE
The pt has suffered from HTN for many years, where does this info go? -
ANSWERSPMHx
There is tenderness of the RUQ - ANSWERSPE
The pt's mother has heart disease - ANSWERSFHx
The diagnosis is upper respiratory infection, where does this info go? -
ANSWERSAssessment
The patient will be prescribed penicillin today, where does this info go? -
ANSWERSPlan
Symptoms of a true allergy - ANSWERSrash, itching, swelling, or difficulty breathing,
NOT adverse reactions (nausea, etc)
Patient says High blood pressure - ANSWERSHTN
Patient says high cholesterol - ANSWERSHLD
Patient says thyroid problem - ANSWERSHypothyroidism, sometimes hyperthyroidism
Patient says diabetes - ANSWERSDM
Patient says I only take pills for diabetes - ANSWERSNIDDM (type 2)
Patient says I take shots (insulin) for diabetes - ANSWERSIDDM (type 1)
Patient says heart disease - ANSWERSusually CAD
100% Accurate!!
Subjective - ANSWERSfrom patient, HPI, ROS
Objective - ANSWERSfrom physician, PE, Lab, imaging
Pain - ANSWERSsubjective from patient
Tenderness - ANSWERSobjective from physician
Benign - ANSWERSNormal, nothing of concern
Acute - ANSWERSNew onset, <3 months
Chronic - ANSWERSLong standing, >3 months
Baseline - ANSWERSAn individual's normal state of being
Auscultation - ANSWERSListening with a stethoscope (heart, lungs, abdomen)
Palpation - ANSWERSThe act of pressing on an area (by a 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
Meaningful Use - ANSWERSa set of government mandated criteria that must be
obtained for every patient: Chief Complaint, 5 vital signs, height, weight, BMI, smoking
status if >13 y/o
Medical Decision Making - ANSWERSThe physicians thought process
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 cannot - ANSWERStouch patients, partake in any activity that may affect
patient health, handle bodily fluids or specimens, sign or authenticate any chart or
record, give verbal orders or submit electronic orders
Are physician assistants and nurse practitioners considered medical providers? -
ANSWERSYes, mid-level
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWERSFalse
What will the scribe document for the outpatient visit?
Important notes for past medical records
History & Physical
Laboratory and radiology results
Physician interpretation of XRs and EKGs
Assessment
Plan - ANSWERSAll of the above
Types of Patients - ANSWERSNew and Established
New patient - ANSWERSNo previous record in the last 3 years, longer visit, detailed
chart
Established patient - ANSWERSPrevious records available from last 3 years, even if
from different physician in same building, shorter visit, concise chart
Types of Clinic visits - ANSWERSDiagnostic and Health Maintenance/Management
Diagnostic visit - ANSWERSacute problem, chief complaint = new symptom, goal is to
determine the cause of the problem and appropriate treatment, diagnose
Health Maintenance/Management visit - ANSWERSChronic symptom, every 3-4
months, chief complaint = management of chronic problem, goal is to assess progress
of ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? -
ANSWERSEstablished
,A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - ANSWERSDiagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be? - ANSWERSHealth Maintenance/Management
Clinic Flow - ANSWERSCheck-in, Physician Evaluation, Orders & Results, Assessment
& Plan, Check-Out
Meaningful Use - ANSWERSChief Complaint, 5 Vital Signs, Height, Weight, BMI,
Smoking Status (>13y/o)
Vital Signs - ANSWERSHR, BP, Pulse Ox, Temperature, Resp. Rate
Nurse/MA assessment - ANSWERSConfirm CC, review allergies/medications, brief past
medical history
Physician Evaluation - ANSWERSReview patient's medical record (a&p from last visit),
History and Physical (H&P), Differential Dx (only diagnostic)
Orders - ANSWERSLab studies, imaging, procedures,
Results - ANSWERSMay result during visit, probably in a few days
Assessment - ANSWERSlist of Dx
Plan - ANSWERSWho to see, When to f/u, Instructions
Check-out - ANSWERSHome or ED, education on illness provided, schedule f/u
Who is the first person to speak with the patient after he/she is placed in a room? -
ANSWERSNurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - ANSWERS5
Vital (BP, HR, Temp, O2 sat, RR), BMI, height, weight, smoking, CC
What does H&P abbreviate and who performs this? - ANSWERSHistory & Physical, by
the physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWERSNo
What Information will be included in the patient's plan? - ANSWERSWho to see, when
to see, and instructions
Name of doc system and online or paper? - ANSWERSNextGen, online
, Sections of a chart - ANSWERSS (HPI and ROS), Hx (PMHx, SHx, FHx), O(PE, Orders
and Results), A (Assessment), P (plan)
Patient complaint goes in - ANSWERSHPI or ROS (if HPI, goes in ROS)
The CBC shows anemia, where does this info go? - ANSWERSResults
The EKG shows Normal Sinus Rhythm, where does this info go? - ANSWERSResults
The pt came to the clinic for CP, where does this info go? - ANSWERSHPI and ROS
The pt came in for CP but also stubbed his toe, where does this info go? -
ANSWERSROS if not mentioned in HPI
The pt is in no acute distress, where does this info go? - ANSWERSPE
The pt has suffered from HTN for many years, where does this info go? -
ANSWERSPMHx
There is tenderness of the RUQ - ANSWERSPE
The pt's mother has heart disease - ANSWERSFHx
The diagnosis is upper respiratory infection, where does this info go? -
ANSWERSAssessment
The patient will be prescribed penicillin today, where does this info go? -
ANSWERSPlan
Symptoms of a true allergy - ANSWERSrash, itching, swelling, or difficulty breathing,
NOT adverse reactions (nausea, etc)
Patient says High blood pressure - ANSWERSHTN
Patient says high cholesterol - ANSWERSHLD
Patient says thyroid problem - ANSWERSHypothyroidism, sometimes hyperthyroidism
Patient says diabetes - ANSWERSDM
Patient says I only take pills for diabetes - ANSWERSNIDDM (type 2)
Patient says I take shots (insulin) for diabetes - ANSWERSIDDM (type 1)
Patient says heart disease - ANSWERSusually CAD
