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Scribe > Class 1 > Flashcards

Class 1 Flashcards

1
Q

EHR

A

electronic health record

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2
Q

What is the role of the scribe?

A

to share the clinician’s burden of data gathering and chart documentation

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3
Q

What can scribes not do?

A

touch patients, write orders or prescriptions, give verbal orders, sign anything on behalf of provider, handle bodily fluids or specimens

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4
Q

Chief complaint

A

the main reason for the patient’s outpatient visit

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5
Q

EMR / EHR

A

electronic medical record / electronic health record

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6
Q

Subjective

A

feeling

oftentimes how a patient says they are feeling

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7
Q

Objective

A

factual findings from the provider

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8
Q

Pain

A

patient’s feeling of discomfort

subjective

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9
Q

Tenderness

A

Doctor’s finding of reproducible pain

objective

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10
Q

Acute

A

new onset, likely concerning

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11
Q

Chronic

A

Long-standing, not of direct concern

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12
Q

What constitutes a new patient?

A

A patient that has never been seen at the organization

A patient that was seen 3 years or more ago

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13
Q

If a patient goes to a different clinic within the same organization are they a new patient?

A

No, their information is available in the charts

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14
Q

Diagnostic exams

A

Address a new concern

The chief complaint is a new symptom

Goal is to determine the cause of the problem and treatment plan

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15
Q

Health management exams

A

Check-ups

The chief complaint is a routine physical or management of chronic problems

Goal is preventative care and/or assessing progress of ongoing medical problems

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16
Q

What is the order of the clinic flow?

A
  1. Check In and Chief Complaint
  2. History and Physical
  3. Orders and Results
  4. Assessment and plan
  5. Check Out
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17
Q

Who does the Check-In and Chief Complaint?

A

Nurse or MA

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18
Q

What are the 5 vital signs?

A 
HR: heart rate (bpm)
BP: blood pressure (mmHg)
RR: respiratory rate 
T: temperature 
SaO2: Oxygen saturation (%)
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19
Q

HPI

A

History of Present Illness

the story and context of the chief complaint

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20
Q

ROS

A

review of systems

a head-to-toe list of positive and negatives

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21
Q

PE

A

physical exam

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22
Q

DDx

A

list of possible diagnoses (Dx) that could be causing patient’s complaints

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23
Q

What type of visits do DDx occur?

A

only at diagnostic visits

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24
Q

What is the acronym for the structure of the medical chart?

A

SOAP

subjective, objective, assessment, plan

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25
Q

Subjective parts of medical chart

A

History of Present Illness (HPI)

Review of Systems (ROS)

Past history (kinda)

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26
Q

What are the four parts of patient history?

A

medical, surgical, social and family

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27
Q

Objective parts of medical chart

A

Physical examination (PE)

Orders and results

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28
Q

What goes in the assessment part of chart?

A

current diagnoses

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29
Q

What goes in the Plan part of chart?

A

treatment plan and follow-up

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30
Q

PMHx

A

past medical history

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31
Q

High blood pressure

A

hypertension (HTN)

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32
Q

High cholesterol

A

Hyperlipidemia (HLD)

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33
Q

Diabetes

A

Diabetes Mellitus (DM)

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34
Q

“I only take pills for my diabetes”

A

Non-insulin dependent diabetes mellitus

NIDDM

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35
Q

“I only take shots for my diabetes”

A

Insulin dependent diabetes mellitus

IDDM

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36
Q

Heart disease

A

Coronary Artery Disease

CAD

37
Q

Heart attack

A

Myocardial Infarction

MI

38
Q

Heart failure

A

Congestive heart failure

CHF

39
Q

Irregular heartbeat

A

Arrhythmia

40
Q

Emphysema or chronic bronchitis

A

Chronic Obstructive Pulmonary Disease

COPD

41
Q

Blood clot in lung

A

Pulmonary Embolism

PE

42
Q

Pneumonia or lung infection

A

Pneumonia

PNA

43
Q

Reflux

A

Gastroesophageal Reflux Disease

GERD

44
Q

Ulcers

A

Gastric/Peptic Ulcer Disease

PUD

45
Q

Irritable bowel

A

Irritable bowel syndrome

IBS

46
Q

Bladder infection

A

Urinary tract infection

UTI

47
Q

Kidney infection

A

Pyelonephritis

48
Q

I’m on dialysis

A

Chronic Kidney Disease

CKD

49
Q

Enlarged prostate

A

Benign Prostatic Hypertrophy

BPH

50
Q

Stroke

A

Cerebrovascular Accident

CVA

51
Q

blood clot in brain

A

ischemic CVA

52
Q

Brain bleed

A

Hemorrhagic CVA

53
Q

Mini stroke

A

transient ischemic attack

TIA

54
Q

Blood clot in my leg

A

Deep vein thrombosis

DVT

55
Q

Bulge in my aorta

A

Aortic aneurysm

56
Q

Bad blood flow in my legs

A

Peripheral vascular disease

PVD

57
Q

Cancer

A

Cancer or Carcinoma

CA

58
Q

Spread to my …

A

With metastasis to the …

59
Q

Chemo

A

chemotherapy

60
Q

Radiation

A

radiation therapy

61
Q

“they cut it out”

A

Status-post surgical resection

62
Q

Cancer is gone

A

In remission

63
Q

When does scribe have to pay attention to home medications?

A

If they are part of the HPI / story the patient brought

64
Q

True allergy to medicine

A

rash, itching, swelling, or difficulty breathing

65
Q

Adverse reaction

A

reaction to medicine that does not constitute as a true reaction

66
Q

PSHx

A

past surgical history

67
Q

Tonsils removed

A

Tonsillectomy

68
Q

-ectomy

A

suffix that means removal

69
Q

Adenoids removed

A

Adenoidectomy

70
Q

“Neck arteries cleaned”

A

Carotid endarterectomy

71
Q

Leg amputated

A

above knee amputation (AKA)

below knee amputation (BKA)

72
Q

Joint repair

A

arthroplasty

73
Q

Balloon in my heart

A

Balloon angioplasty

74
Q

Stents in my heart

A

coronary stents

75
Q

Heart bypass

A

coronary artery bypass graft

CABG

76
Q

breast removal

A

mastectomy

77
Q

part of my lung removed

A

partial lobectomy

78
Q

appendix removed

A

appendectomy

79
Q

gallbladder removed

A

cholecystectomy

80
Q

Part of my colon removed

A

partial colectomy

81
Q

Spleen removed

A

splenectomy

82
Q

kidney removed

A

nephrectomy

83
Q

uterus removed

A

hysterectomy

84
Q

ovary removed

A

oophorectomy

85
Q

FHx

A

family history

includes any medical condition present in the patient’s blood relatives

86
Q

What age indicates a higher genetic risk?

A

under 55

if relative developed a disease under 55, it is a higher chance of being a genetic disease

87
Q

SHx

A

social history

88
Q

What goes in the SHx?

A

alcohol use, tobacco use, drug use, occupation, living circumstances

89
Q

How do you record tobacco use?

A

ppd

packs per day

Scribe (6 decks)

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