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What medical term describes the surgical removal of the gallbladder? cholecystectomy What does "PHI" stand for? Expand the abbreviation. Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? craniotomy A patient's PCP is on vac...

Inpatient Admitted to the hospital overnight ED Flow Check in and CC --> Physician Assessment --> Objective Orders and Results --> MDM --> Disposition ED Flow Before Orders Walk-in --> Triage (& vitals) --> Bed placement --> Nurse Assessment --> Hisotry and Physical --> Orders ED Flow After Orders Differential Dx --> Orders --> Lab, Procedures, Meds, Imaging --> Results --> Final Dx --> Disposition Template Layout HPI --&...

Fill in the blanks for ED Flow: Walk in > Blank 1 > Bed > Physician Assessment > Lab/Rad/Meds > Results > MDM > Diagnosis > Consults > Blank 2 Triage, Disposition What are the 3 disposition options? Discharge, Admit, Transfer What are the 5 vital signs? Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation The HPI and ROS are what type of information (subjective or objective)? subjective The Physical Exam is what t...

What does ROS stand for? Review of Systems The HPI and ROS are considered what type of information? Subjective The physical exam (PE) is what type of information? Objective If a physician told you a patient's abdomen was nontender or the patient's skin was pale, where would you document these pieces of information? Physcal Exam (PE) What section focuses directly on the chief complaint? History of Present Illness (HPI) What are the five vital signs? Hear...

What is the standard template for charting? HPI, ROS, Past History, PE, ED Course, Disposition What are some general PMHx? Hypertension (HTN), Hyperlipidemia, Cancer, Diabetes Mellitus (IDDM, NIDDM) What are some cardiac PMHx? Myocardial Infarction, Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation What are some pulmonary PMHx? Pulmonary Embolism, Pneumonia, Chronic Obstructive Pulmonary Disease, Asthma What are some abdominal PMx? GERD, AAA,...

Three types of laboratory Studies Blood, Urine and Cultures Complete Blood Count (CBC) components White Blood Cells(WBC), Hemoglobin(Hgb), Hematocrit (Hct), Platelets (Plt) Significance of high WBC Infection Significance of low Hgb and Hct Anemia Significance of low Plt Prone to bleeding CBC with Differential Components Complete Blood Count (CBC), Band Cells (Bands), Segmented Neutrophils (Segs), Lymphocytes (Lymphs), Monocytes (Monos), Eosinophils (Eos) ...

What are the necessary elements to include in the HPI, ROS, PMH/FH/SH, and PE to qualify for level 5 billing? HPI: 4 elements ROS: 10 systems PMH/FH/SH: 2 of 3 PE: 8 systems (excluding head and neck) what is medical decision making? the physician's thought process (MDM) benign (def) nothing of concern febrile (def) the state of having a fever, concerning for infection acute (def) new onset, likely concerning distress (def) the doctor's judgement of d...

What does "IDDM" stand for? Do not include any hyphenations for your answer. Insulin Dependent Diabetes Mellitus What does "AMS" stand for? Altered Mental Status A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not? Yes, because the fever started soon after the cough Match each critical care dx with it's associated procedure. Respi...

A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? acute urinary tract infection in pregnancy, 2nd trimester A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. What is the...

Subjective vs. Objective Feeling vs. Fact Chief Complaint (CC) The main reason for the patient's ED visit Medical Decision Making (MDM) The physician's thought process Pain vs. Tenderness patient's feeling vs. physician's assessment (subjective) Benign Normal, nothing of concern Distress The doctor's judgement of discomfort (objective) Febrile The state of having a fever, concerning for infection Acute New onset, likely concerning ...

High blood pressure layman's Hypertension Hypertension (abbv) HTN High cholesterol layman's Hyperlipidemia Hyperlipidemia (abbv) HLD Diabetes layman's Diabetes mellitus Diabetes mellitus (abbv) DM "I only take pills for my diabetes" NIDDM (Type 2) "I take insulin for my diabetes" IDDM (Type 1) Heart disease layman's Usually coronary artery disease Coronary artery disease (abbv) CAD Heart failure layman's Co...

How would you diagnose Hemmorrhagic CVA? LP or Head CT Which of the following lab results need to be monitored closely for efficiency? D-Dimer Troponin Creatinine (from BMP) Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? CBC, BMP, Troponin, EKG, CXR What procedure would be used to diagnose Meningitis? Expand the abbreviation. Lumbar Puncture Which of the following would be ordered to investigate thyroid disease? ...

What are the 3 types of dispositions? Discharge, Admit, Transfer What does HPI stand for? history of present illness What does ROS stand for? review of systems The HPI and ROS are considered what type of information? subjective The physical exam is what type of information? objective If a physician told you a patient's abdomen was non tender, where would you document this? PE What section focuses directly on the chief complaint? HPI If som...

Chief Complaint the main reason for the pt's ED visit pain vs tenderness pt's feelings (subjective) vs physician's assessment (objective) distress the doctor's judgement of discomfort baseline an individual's normal state of being What CAN scribes do? -Document Hx, PE, results, procedures, and physician consults -Access and document lab results and radiology findings -Locate and obtains PMHx, previous charts, past results, and recent studies -Record physi...

A ___ is a ___ of ___ in the ___ page that gives users access to different ___. Git Operation; course; actions; User Story Commit; commit behavior operations Apex is an ___ programming language developed by Salesforce. An ___ is a ___ that contains ___ and ___ enabling users to create ___. object-oriented; Apex class; coding template; variables; methods; objects A ___ is an ___ that ___ creates when you ___ to a ___. feature branch; auxiliary branch; Copado; commit cha...

What are some of the challenges in the development lifecycle Copado helps address? Limited set of quality checks. Lack of monitoring and compliance. The struggle of migrating data from multiple objects. All are correct. (Correct) Which of the following is an element that helps you track changes but is not required in order to work with Copado? Pipeline Release How can you access the feature branch in your Git repository directly from a user story? Using the link in the View ...

What is Copado? A scalable SF native platform that provides value in every stage of the SF DevOps process How does Copado solve the lack of compliance? It includes a compliance hub tool that allows you t scan all the metadata changes made in your environments in order to find security breaches How can Copado help you manage releases in an agile way? (2) Provides you with built-in agile tools Supports integrations with external ALM systems Copado provides a conflict resol...

Dave has been assigned the task of deleting a custom object. After committing the destructive changes, he notices that no feature branch has been created. What could be the reason? Base brach was set to master branch and then component was not in production. What happens with the previously created commit records in the User story after recommitting files using the Re-Create feature branch functionality? Their status is changed to Commit not in Branch Which is NOT true about dest...

Debbie committed some changes to the Opportunity Layout but, after deploying her changes from DEV to INT, she found her changes were not there due to an auto-resolved Git conflict she was not aware of. How can she prevent this from happening again in all future promotions? Add Layout to the Exclude From Auto Resolve multi-select picklist field in the Pipeline record Dave committed a new method on the AccountOperations class but, after deploying his changes from DEV to INT, he found his c...

Recommit Files A git operation that enables you re recommit components, remove components from User Story Selections, and re-create the user story feature branch Re-Create Feature Branch checkbox that appears when Recommit files is selected as the git operation. Used in cases where metadata was committed by mistake or is no longer needed in the user story. When checked, existing commits won't be present in the new feature branch and previous commit status will be 'Commit Not in Branch...