Scribe America Outpatient Day 1 Exam Questions With Correct Answers

Subjective vs objective: - Answer Feeling (patient) vs fact (provider) Pain vs Tenderness: - Answer patient's feeling (subjective) vs physician's observation (objective) Benign: - Answer Normal, nothing of concern Acute vs chronic: - Answer new onset vs long standing [does not indicate severity] Baseline: - Answer individual's normal state of being Auscultation: - Answer listening with a stethoscope Palpation: - Answer the act of pressing on an area (by the physician) Inpatient: - Answer Admitted to the hospital for an overnight Outpatient (OP): - Answer Seen and sent home the same day Chief complaint (CC): - Answer The main reason for the patient's visit Medical Decision Making (MDM): - Answer The physician's thought process Mid-level provider (MLP) - Answer works under the supervision of a physician to diagnose and treat patients. Includes Advanced practice provider (APP) Nurse Practitioner (NP) or Physician Assistant (PA) Nurse or Medical Assistant - Answer " Nurse or Medical Assistant (MA): Records medical - Answer histories and symptoms, monitors the patient, completes - Answer meaningful use requirements, administers medications, - Answer assists with procedures" - Answer Receptionist - Answer • Receptionist: Answers 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 - Answer • Scribe: Documents the patient's visit on behalf of the physician What can a scribe do? - Answer Document the hisotry, physical exam, results, procedures, assessment and plan. - access and document laboratory results and radiology findings. - location and obtain PMHx, previous charts, past results, and recent studies. - Record physician interpretations of x-rays and EKGs What can't a scribe do? - Answer Partake in any activity that may affect patient health or outcome, touch patients, handle fluids or specimens, sign or authenticate any chart or record, or give verbal orders or submit electronic orders. What are the two types of patients? How are they different? - Answer New: No previous records, longer visit, more detailed chart [if its been more than 3 years since they've visited, they're new] Established:Previous records available, shorter visit, concise chart [must have been seen in the clinic within 3 years] What are the two types of clinic visits? - Answer Diagnostic: New problem, chief complaint is a new symptom, goal is to determine the cause of the problem and appropriate treatment. Health Management: Check up, chief complain is routine physical or management of chronic problems. Goal is preventative care and/or assessing medical problems What are the main categories of a patient's chart? - Answer Subjective, Objective, Assessment, and Plan What things do you include under the subjective portion of a patient's chart? - Answer Their experiences. Includes the HPI (chief complaint), ROS (any symptoms, NOT DISEASE) What things do you include under the objective portion of a patient's chart? - Answer Physical exam (everything you do in the room), past medical history (prior dx), labs and results The H&P stands for what (and includes what?) - Answer Stands for history and PE, includes the HPI, ROS and PE What information would you put under the HPI of a chart? - Answer Symptoms and past Dx that relate to chief complaint What information would you put under the ROS portion of a patient's chart? - Answer Any symptoms the patient mentions What information would you put under the Past History portion of a patient's chart? - Answer Medical/Surgical Hx, SHx + FHx What information would you put under the Assessment & Plan portion of a patient's chart? - Answer final dx, treatment plans + f/u, any rx (basically what's wrong, what are we gonna do) Where would you put a patient complaint? - Answer The HPI or ROS Where would you pust a past diagnosis or surgery? - Answer past Hx Where would you put a physician's observation? - Answer Objective (PE) Where would you put the results of a lab/study? - Answer Results Where would you put the current diagnosis? - Answer Assessment Patient says: High blood pressure - Answer Hypertension (HTN) Patient says: High Cholesterol - Answer Hyperlipidemia (HLD) Patient says: Thyroid Problem - Answer hypothyroidism (sometimes hyperthyroidism) Patient says: Diabetes - Answer diabetes melitis (dm) Patient says: "All I have to take for my diabetes are the pills" - Answer NIDDM (typically type 2)