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
Gynecological PMHx| G: P: A: definition and meaning?
G: Gravida - total number of times the patient has been pregnant
P: Para - number of pregnancies that resulted in birth
A: Abortion - total number of miscarriages or elective abortions
Neurological PMHx: patient says, brain bleed (stroke)
scribe writes, hemorrhagic CVA
Neurological PMHx: patient says, stroke
scribe writes, ischemic cerebrovascular accident (CVA)
*note: ischemia = lack of blood supply
Neurological PMHx: patient says, mini-stroke
scribe writes, transient ischemic attack (TIA)
Neurological PMHx: patient says, seizures
scribe writes, history of seizures
*note: there is a difference between history of seizures and the diagnosis of epilepsy: seizures can be acute and provoked (caused by a known reason) while epilepsy is classified by two or more seizures, the reason for which is unknown
Psychological PMHx: patient says, bipolar
scribe writes, bipolar disorder
Psychological PMHx: patient says, schizophrenia
scribe writes, schizophrenia
Psychological PMHx: patient says, “I drink a lot”
scribe writes, ETOH abuse or alcoholism
Psychological PMHx: patient says, “I do drugs”
scribe writes, substance abuse
Vascular PMHx: patient says, “Blood clot in my leg”
vascular = relating to vessel(s) which carry blood, aka blood vessels (i.e. veins, arteries)
scribe writes, lower extremity deep vein thrombosis (DVT)
Vascular PMHx: patient says, “Bulge in my aorta”
scribe writes, aortic aneurysm
Vascular PMHx: patient says, “Bad flow to my legs”
scribe writes, peripheral vascular disease (PVD)
Vascular PMHx: patient says, “Numbness in my legs”
scribe writes, peripheral neuropathy
Musculoskeletal PMHx: patient says, low back pain
scribe writes, chronic low back pain
Musculoskeletal PMHx: patient says, bulging/herniated disc
scribe writes, degenerative disc disease (DDD)
Musculoskeletal PMHx: patient says, arthritis
scribe writes:
- usually, osteoarthritis (OA)
- sometimes, rheumatoid arthritis (RA)
- note: RA is an autoimmune arthritis (immune sys. attacks lining of joints)
Musculoskeletal PMHx: patient says, weak/fragile bones
scribe writes:
- often, osteoporosis
Cancer PMHx: patient says, cancer
scribe writes, cancer or carcinoma (CA): brain, breast, lung, colon, prostate, ovary, skin, bone, leukemia, or lymphoma
*note: CA is used for cancer or carcinoma
Cancer PMHx: patient says, “Spread to my….”
scribe writes:
with metastasis to the…
Cancer PMHx: patient says, chemo
scribe writes, chemotherapy
Cancer PMHx: patient says, radiation
scribe writes, radiation therapy
Cancer PMHx: patient says, “They cut it out”
scribe writes, status post surgical resection
Cancer PMHx: patient says, “It’s gone”
scribe writes, in remission
PMHx
Past Medical History
PSHx
Past Surgical History
FHx
Family History
suffix -ectomy
surgical removal
suffix -otomy
opening of the skin; cutting into a part of the bosy
ENT PSHx: patient says, tonsils removed
*note: ENT = ear, nose, and throat
scribe writes, tonsillectomy
ENT PSHx: patient says, adenoids removed
scribe writes, adenoidectomy
ENT PSHx: patient says, ear tubes
scribe writes, myringotomy or pressure equalizing (P.E.) tubes
Cardiovascular PSHx: patient says, heart bypass
scribe writes, coronary artery bypass graft (CABG) –> PMHx CAD
Cardiovascular PSHx: patient says, stents
scribe writes, coronary stents –> PMHx CAD
Cardiovascular PSHx: patient says, heart cath
scribe writes, cardiac catherterization
Cardiovascular PSHx: patient says, balloon
scribe writes, angioplasty –> PMHx CAD
Cardiovascular PSHx: patient says, valve surgery
scribe writes, valve repair or replacement (Bovine vs. Mechanical)
Cardiovascular PSHx: patient says, pacer
scribe writes, pacemaker
Cardiovascular PSHx: patient says, defibrillator
scribe writes, automatic implanted cardiac defibrillator (AICD)
Cardiovascular PSHx: patient says, surgery for Afib
*note: Afib = atrial fibrillation
scribe writes, Afib s/p cardiac ablation
Pulmonary/Chest PSHx: patients says, breast removal
scribe writes, mastectomy
Pulmonary/Chest PSHx: patients says, hole in my neck
scribe writes, tracheotomy (commonly called a “trach”)
Pulmonary/Chest PSHx: patients says, part of my lung removed
scribe writes, partial lobectomy
Gastrointestinal PSHx: patients says, appendix removed
scribe writes, appendectomy
Gastrointestinal PSHx: patients says, gallbladder removed
scribe writes, cholecystectomy
Gastrointestinal PSHx: patients says, hernia repair
scribe writes, herniorrhaphy
Gastrointestinal PSHx: patients says, part of my colon removed
scribe writes, partial colectomy
Gastrointestinal PSHx: patients says, bag to collect stool
scribe writes, colostomy
Gastrointestinal PSHx: patients says, spleen removed
scribe writes, splenectomy
Gastrointestinal PSHx: patients says, stomach stapled
scribe writes, bariatric surgery (gastric sleeve, gastric band/lap/band, gastric bypass, etc.)
Gastrointestinal PSHx: patients says, exploratory
scribe writes, exploratory laparoscopy (Ex Lap)
Genitourinary PSHx: patients says, kidney removed
scribe writes, nephrectomy
Genitourinary PSHx: patients says, uterus removed
scribe writes, hysterectomy (partial vs. total)
Genitourinary PSHx: patients says, ovary removed
scribe writes, oophorectomy
Genitourinary PSHx: patients says, ovary and fallopian tubes removed
scribe writes, salpingo-oophorectomy
Genitourinary PSHx: patients says, tubes tied
scribe writes, tubal ligation (female) or vasectomy (male)
Genitourinary PSHx: patients says, C-section
scribe writes, cesarean section
Genitourinary PSHx: patients says, prostate removed
scribe writes, prostatectomy or prostate resection (most often Transurethral Resection of the prostate, or TURP)
Genitourinary PSHx: patients says, uterine product removed
scribe writes, dilation and curettage (D&C)
Neurological PSHX: patient says, neck artery cleaned
scribe writes, carotid endarterectomy
Neurological PSHX: patient says, shunt
scribe writes, cerebral shunt
Neurological PSHX: patient says, brain surgery
scribe writes, craniotomy (brain bleed vs. brain CA)
Vascular PSHX: patient says, dialysis fistula
scribe writes, AV (arteriovenous fistula)
Vascular PSHX: patient says, dialysis graft
scribe writes, AV graft
Vascular PSHX: patient says, PICC Line
scribe writes, peripherally inserted central catheter (PICC)
Vascular PSHX: patient says, port
scribe writes, Port-a-cath or Medi-Port
Vascular PSHX: patient says, clot filter (lower abdomen or leg)
scribe writes, IVC (inferior vena cava) filter
Orthopedic PSHx: patient says, leg amputated
scribe writes, above knee amputation (AKA) or below knee amputation (BKA)
Orthopedic PSHx: patient says, joint repair
scribe writes, arthroplasty
Orthopedic PSHx: patient says, metal plates/pins
scribe writes, hardware
Orthopedic PSHx: patient says, neck fused
scribe writes, cervical spinal fusion
Orthopedic PSHx: patient says, back fused
scribes writes, spinal fusion
Orthopedic PSHx: patient says, new hip
scribe writes, total hip replacement
home medication and allergies are usually documented by the nurse of MA, not the scribe
Any medication that causes a rash, itching, swelling, or difficulty breathing is a true allergy; any other response is an “adverse” reaction
Family History (FHx) important info
- age of onset for each dz is very important to Fx b/c it helps determine the genetic risk factors
- **a younger age of onset means higher genetic risk
- older age of onset is more likely due to environment than genetics
- genetic risk for a dz is higher if multiple blood related family members suffer from the same disease
general FHx (physicians commonly ask about)
HTN, DM, CA
cardiac FHx
MI/CAD less than 55 y/o
pulmonary FHx
PE, asthma
gastrointestinal FHx
Crohn’s, IBS
neurological FHx
CVA, aneurysm, seizures
miscellaneous FHx
sickle cell anemia, DVT
5 categories of social history (SHx)
tobacco use, alcohol use (ETOH), illicit drug use, occupation, living circumstances
SHx on tobacco use
note: if your clinic reports smoking cessation as a quality measure, it is required that smoking status is documented on every patient 13 y/o and up
- smoking status
- current (#ppd, #yrs)
- former (year quit)
- never
- second smoke exposure (ped)
- E-cigarettes - chewing tobacco
SHx on alcohol use
- never
- occasionally/socially
- daily
- chronic alcoholic
- number of drinks/day
- type of alcohol (beer/wine/liquor)
SHx on illicit drug use
- which drug
- heroin
- cocaine
- methamphetamine
- THC
- narcotics - route of administration
- oral
- inhaled
- injected - date of last use
SHx on occupation
- employed
- unemployed
- on disability
- retired
*if a physician asks specifically about a type of work, be sure to document it
SHx on living circumstances
- lives alone
- with family/friends
- nursing home/assisted living
- hospice
- homeless/shelter
Pediatric SHx
*there are a few social history components that are unique to pediatric patients as they often cannot verbalize their home/life situation
- caretaker (mother, father, grandparent)
- attend daycare
- attend school
- have brothers/sisters
- second-hand smoke exposure
- immunizations up-to-date
