Basics

Question 1

Scribe Dos and Donts

Answer 1

Can’t touch the patient, give orders, or prescribe medication.

Question 2

Chief Complaint

Answer 2

Primary reason for patient to come in.

Question 3

EMR/EHR

Answer 3

Electronic medical record/Electronic Health Record

Question 4

Subjective

Answer 4

What the patient is feeling

Question 5

Objective

Answer 5

Factual finding of discomfort

Question 6

Pain

Answer 6

Patient’s feeling of discomfort

Question 7

Tenderness

Answer 7

Doctor’s finding of reproducible pain

Question 8

Acute

Answer 8

New onset, likely concerning

Question 9

Chronic

Answer 9

Long-standing, not of direct concern [at least 3 months]

Question 10

New Patients

Answer 10

A patient that hasnt been seen before or greater than 3 years. No previous records, longer visit, and detailed chart.

Question 11

Established Patients

Answer 11

Has been seen at the clinic within the last 3 years. Previous records available, shorter visit, concise chart.

Question 12

Diagnostic visit

Answer 12

New problem. Chief complaint, new symptom. Goal is to determine cause of problem and appropriate treatment.

Question 13

DX

Answer 13

Definitive diagnosis. What a provider is certain beyond a reasonable doubt the cause of a problem to the chief complaint.

Question 14

DDX

Answer 14

Differential Diagnosis. A provider is not yet certain beyond a reasonable doubt of cause of chief complaint.

Question 15

Health Management

Answer 15

Check up. Chief complaint: Routine physical or management of chronic problem[s]. Goal is preventative care and/or assessing progress of ongoing medical problems.