SCRIBE UNIVERSITY OP FINAL EXAM
STUDY GUIDE QUESTIONS AND
ANSWERS
Lateral - Answer-Further from the midline of the body
Diffuse - Answer-Widespread (opposite of localized)
Diagnosis - Answer-What the physician has determined to be the most likely cause of
the patient's symptoms
Assessment - Answer-A list of the patient's current diagnoses
Plan - Answer-The currently laid out course of action to address the patient's condition
Prognosis - Answer-A forecast of the likely course of a disease or ailment
Follow-up - Answer-On-going contact with healthcare providers in order to address a
health concern
The assessment always includes... - Answer-Diagnosis (and/or differential)
The assessment can include... - Answer-Brief summary of the HPI, brief summary of
physical exam, summary of lab/imaging results, prognosis
The three assessment structures are... - Answer-Simple statement, brief summary,
comprehensive summary
Simple statement includes: - Answer--Age and sex of patient
-Past medical history only if relevant
-Diagnoses
Brief summary includes: - Answer--Age and sex of patient
-Past medical history, if relevant
-Physical exam findings, if relevant
-Results, if new and relevant
-Diagnoses
-Differential, if no definitive diagnosis is found
Comprehensive summary includes: - Answer-• Age and sex of patient
• Summary of PMHx
• Summary of HPI, including CC, onset, and
important elements
, • Summary of PE
• Summary of results
• Diagnoses
• Differential, if applicable
• Prognosis, if applicable
The assesment is typically written in... - Answer-complete sentences
Only include results that are ______ related to the patient's diagnosis or differential -
Answer-directly
Pertinent results include: - Answer-• Positive results confirming a diagnosis
• Negative results that have ruled out a diagnosis
Include the following items when summarizing test results: - Answer-• Name of test
• Result of test
• Why it was ordered (the differential the test is ruling out or confirming)
The plan is at the... - Answer-Bottom of the chart
The plan is written in... - Answer-Bullets, numbers, or spacing
Context - Answer-Is there anything else that's important?
Is the CC an element? - Answer-NO
Single complaint formula is best for... - Answer-patients with only 1-2 complaints that
have not been previously evaluated
Single complaint formula format: - Answer-1. age and sex of the patient
2. complaint and onset
3. quality, timing, and location
4. modifying factors
5. list associated symptoms and pertinent negatives
6. describe any other important context
Multiple complaint formula is best for... - Answer-Patients who have:
1. multiple complaints
2. routine follow-up for chronic illness
3. different treatment plans for different complaints
Multiple complaint formula format: - Answer-1. introduction
2. paragraph 1 (condition 1)
3. paragraph 2 (condition 2)
4. paragraph 3 (condition 3)
5. paragraph 4 (condition 4)
STUDY GUIDE QUESTIONS AND
ANSWERS
Lateral - Answer-Further from the midline of the body
Diffuse - Answer-Widespread (opposite of localized)
Diagnosis - Answer-What the physician has determined to be the most likely cause of
the patient's symptoms
Assessment - Answer-A list of the patient's current diagnoses
Plan - Answer-The currently laid out course of action to address the patient's condition
Prognosis - Answer-A forecast of the likely course of a disease or ailment
Follow-up - Answer-On-going contact with healthcare providers in order to address a
health concern
The assessment always includes... - Answer-Diagnosis (and/or differential)
The assessment can include... - Answer-Brief summary of the HPI, brief summary of
physical exam, summary of lab/imaging results, prognosis
The three assessment structures are... - Answer-Simple statement, brief summary,
comprehensive summary
Simple statement includes: - Answer--Age and sex of patient
-Past medical history only if relevant
-Diagnoses
Brief summary includes: - Answer--Age and sex of patient
-Past medical history, if relevant
-Physical exam findings, if relevant
-Results, if new and relevant
-Diagnoses
-Differential, if no definitive diagnosis is found
Comprehensive summary includes: - Answer-• Age and sex of patient
• Summary of PMHx
• Summary of HPI, including CC, onset, and
important elements
, • Summary of PE
• Summary of results
• Diagnoses
• Differential, if applicable
• Prognosis, if applicable
The assesment is typically written in... - Answer-complete sentences
Only include results that are ______ related to the patient's diagnosis or differential -
Answer-directly
Pertinent results include: - Answer-• Positive results confirming a diagnosis
• Negative results that have ruled out a diagnosis
Include the following items when summarizing test results: - Answer-• Name of test
• Result of test
• Why it was ordered (the differential the test is ruling out or confirming)
The plan is at the... - Answer-Bottom of the chart
The plan is written in... - Answer-Bullets, numbers, or spacing
Context - Answer-Is there anything else that's important?
Is the CC an element? - Answer-NO
Single complaint formula is best for... - Answer-patients with only 1-2 complaints that
have not been previously evaluated
Single complaint formula format: - Answer-1. age and sex of the patient
2. complaint and onset
3. quality, timing, and location
4. modifying factors
5. list associated symptoms and pertinent negatives
6. describe any other important context
Multiple complaint formula is best for... - Answer-Patients who have:
1. multiple complaints
2. routine follow-up for chronic illness
3. different treatment plans for different complaints
Multiple complaint formula format: - Answer-1. introduction
2. paragraph 1 (condition 1)
3. paragraph 2 (condition 2)
4. paragraph 3 (condition 3)
5. paragraph 4 (condition 4)
