Course 1: Introduction Flashcards
1. Roles in the clinic and scope of scribes 2. New vs. established patients? Two types of clinic visits? 3. How does a patient move through an outpatient clinic visit? 4. Document patient visits 5. Document PMHx 6. Document past surgical history 7. Document family history 8. Document social history
subjective vs. objective
subj: feeling (patient) vs. obj: fact (provider)
pain vs. tenderness
p: patient’s feeling (subjective) vs. t:physician’s observation (objective)
benign
not of concern; normal
acute vs chronic
acu: new onset vs. chr: long standing
baseline
an individual’s normal state of being
auscultation
listening to sounds arising within organs (such as the lungs) with a stethoscope
palpation
the act of pressing on an area (by the physician)
inpatient
admitted to the hospital overnight
outpatient (op)
seen and sent home the same day
chief complaint (CC)
the main reason for the patient’s visit
mid-level provider (MLP)
Advanced Practice Provider (APP), Nurse Practitioner (NP), or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients
nurse or medical assistant (MA)
records medical histories and symptoms, monitors the patient, completes meaningful use requirements, administers medications, assists with procedures
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
documents the patient’s visit on behalf of the physician
The Scribe Scope: a scribe is an unlicensed person performing documentation and other non-clinical tasks under the direction of a healthcare provider. Scribes CANNOT ___ (pg. 113)
scribes CANNOT: partake in any activity that may affect patient health or outcome; touch patients; handle bodily fluids or specimens; sign or authenticate any chart or record; give verbal orders or submit electronic orders
new patient
no previous record; longer visit; detailed chart
*note: if it has been more than 3 years since the patient has been seen in this clinic, they will be considered new, regardless of being seen prior to their 3 year absence
established patient
previous records available; shorter visit; concise chart
*note: to be considered established, the patient must have been seen in this clinic within 3 years
diagnostic clinic visit
new problem; chief complaint = new symptom; goal is to determine the cause of the problem and appropriate treatment
health management clinic visit
check-up; chief complaint = routine physical or management or chronic problem(s); goal is preventative care and/or assessing progress of ongoing medical problems
Clinic Flow: how does a patient move through an OP clinic visit? (pg. 120)
check in–> physician evaluation–> orders and results–> assessment and plan–> check-out
Clinic Flow: check-in
- patient walks into clinic (diagnostic vs. health management)
- room placement
- Nurse/MA obtain quality measures (CC, height, weight, BMI, smoking status, vitals signs = HR, BP, T, RR, SpO2)
- Nurse/MA assessment (confirm CC, review allergies/medications, brief past medical history)
Clinic Flow: physical evaluation
- review patient’s past medical records (assessment and plan from the previous visit, labs and/or imaging results)
- history and physical (H&P) = HPI (history of present illness), ROS (review of systems), PE (physical exam)
- differential Dx (DDx) only for diagnostic visit = possible Dx that may be causing the symptoms
Clinic Flow: orders and results
- orders (laboratory studies, imaging studies, procedures)
2. results (may result during visit -rare- or in a few days)
Clinic Flow: assessment and plan
- assessment (the list of current diagnoses)
- plan (follow-up with specialist if necessary, instructions for lifestyle and preventative care, follow-up for next routine appointment)
Clinic Flow: check-out
- check-out:
- home vs. sent to the ED
- patient education provided
- patient will often stop at the front desk on the way out to schedule next appointment
How are patients visits documented? (pg. 128)
in a S.O.A.P. chart
*note: for Health Management Visits, you will have a prior note to use as reference; the A.&P. of the prior visit are your guideline for today’s visit - the assessment will give you a summary of history and their chief complaint, as well as findings and the plan from the last visit
S.O.A.P. => subjective
subjective complaints
- patient complaint: HPI (story and context of the chief complaint) or ROS (checklist of pertinent positives and negatives)
- past diagnosis or surgery: past history (PMSHx, SHx, FHx –>past diseases/surgeries, EtOH/tobacco, FHx)
S.O.A.P. => objective
objective evaluation
- physician’s observation: physical exam (provider’s objective findings)
- study: results
- orders
S.O.A.P. => assessment
current diagnosis
S.O.A.P. => plan
treatment and follow-up
General PMHx: patient says, High blood pressure
scribe writes - hypertension (HTN)
General PMHx: patient says, High cholesterol
scribe writes - hyperlipidemia (HLD)
General PMHx: patient says, Thyroid problem
scribe writes - usually hypothyroidism (underactive thyroid), sometimes hyperthyroidism (overactive thyroid)
General PMHx: patient says, “I only take pills for my diabetes”
scribe writes - non-insulin dependent diabetes mellitus (NIDDM)
General PMHx: patient says, Diabetes
scribe writes, diabetes mellitus (DM)
General PMHx: patient says, “I take shots (insulin) for my diabetes”
scribe writes, insulin dependent diabetes mellitus (IDDM)
Cardiac PMHx: pt says, heart disease
scribe writes, usually coronary artery disease (CAD)
Cardiac PMHx: pt says, heart attack
scribe writes, myocardial infarction (MI) and CAD
Cardiac PMHx: pt says, heart failure
scribe writes, congestive heart failure (CHF)
Cardiac PMHx: pt says, irregular heartbeat
*note: irregular heartbeats = palpitations
scribe writes, arrhythmia
Cardiac PMHx: pt says, murmur
scribe writes, heart murmur
Cardiac PMHx: pt says, episodes of abnormally fast/racing heartbeat
scribe writes, supraventricular tachycardia (SVT)
*note: tachycardia = fast HR, >120bpm
Pulmonary PMHx: pt says, asthma
scribe writes, asthma
Pulmonary PMHx: pt says, emphysema/chronic bronchitis
scribe writes, chronic obstructive pulmonary disease (COPD)
Pulmonary PMHx: pt says, blood clot in lung
scribe writes, pulmonary embolism (PE)
Pulmonary PMHx: pt says, pneumonia
scribe writes, pneumonia (PNA)
Gastrointestinal PMHx: pt says, reflux
scribe writes, gastroesophageal reflux disease (GERD)
Gastrointestinal PMHx: pt says, ulcer
scribe writes, gastric ulcer or peptic ulcer disease (PUD)
Gastrointestinal PMHx: pt says, pancreatitis
scribe writes, pancreatitis
Gastrointestinal PMHx: pt says, hepatitis
scribe writes, hepatitis A, hepatitis B, or hepatitis C
Gastrointestinal PMHx: pt says, diverticulitis
scribe writes, diverticulitis (inflammation/infection of diverticula-pockets on the colon-)
Gastrointestinal PMHx: pt says, Crohn’s/UC
scribe writes, Crohn’s disease or ulcerative colitis
Gastrointestinal PMHx: pt says, irritable bowel
scribe writes, irritable bowel syndrome (IBS)
Genitourinary PMHx: pt says, bladder infection
scribe writes, urinary tract infection (UTI)
Genitourinary PMHx: pt says, kidney infection
scribe writes, pyelonephritis (Pyelo)
Genitourinary PMHx: pt says, kidney stones
scribe writes, renal calculi
Genitourinary PMHx: pt says, “I’m on dialysis”
scribe writes, chronic renal failure (CRF) on dialysis or end state renal disease (ESRD)
Genitourinary PMHx: pt says, enlarged prostate
scribe writes, benign prostatic hypertrophy (BPH)
*note: Benign = not harmful , Hypertrophy = enlarged
