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SCRIBE > Lecture 1 > Flashcards

Lecture 1 Flashcards

1
Q

subjective

A

feeling

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2
Q

objective

A

fact

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3
Q

pain

A

patient’s feeling

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4
Q

tenderness

A

physician’s assessment

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5
Q

baseline

A

normal individual’s state of being

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6
Q

auscultation

A

stethoscope listening

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7
Q

inpatient

A

admitted to hospital

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8
Q

outpatient

A

no overnight stay, short visit

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9
Q

chief complaint

A

main reason for patient’s visit

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10
Q

meaningful use

A

a set of govt. mandated criteria - must be obtained for every patient

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11
Q

mid-level provider

A

LNP (NP), PA – works under supervision

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12
Q

nurse / MA

A

records medical histories, symptoms, monitors patient, completes meaningful use req., administers meds, assists with procedures

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13
Q

receptionist

A

answers phones, schedules, answers questions, check out, paperwork

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14
Q

scribe

A

documents patient’s visit on physicians behalf (unlicensed)

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15
Q

medical provider

A

physician or mid-level provider

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16
Q

what scribe documents for outpatient visit

A
  1. notes for past medical records
  2. history & physical
  3. lab + radiology results
  4. physician interpretation of XRs and EKGs
  5. assessment
  6. plan
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17
Q

scribes cannot

A
  1. affect patient outcome
  2. touch patients
  3. handle bodily fluids or specimens
  4. sign or authenticate
  5. give verbal orders / submit EMR
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18
Q

new patients

A

no previous records
longer visit
detailed chart

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19
Q

established patients

A

previous records
shorter visit
concise chart

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20
Q

types of clinic visits

A
  1. diagnostic

2. health management / maintenance

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21
Q

diagnostic visit

A

new problem
chief complaint / new symptom
goal to determine cause

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22
Q

health management

A

check-up
chief complaint / management of chronic issue
goal to assess progress

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23
Q

clinic flow:

A 
check-in
physician eval
orders & results
A & P
check-out
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24
Q

physician eval

A

A. H&P (history and physical):

  1. HPI (history of present illness)
  2. ROS (review of systems)
  3. PE (physical exam)

B. All possible explanations (differential Dx)

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25
Q

Orders & results

A

Orders: lab / imaging / procedures
Results: during visit or in a few days

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26
Q

physician eval

A

A&P

Labs / imaging results

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27
Q

A&P

A

assessment: list of Dx
plan: F/U, lifestyle or preventative, F/U for next appt

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28
Q

First person to speak to patient after in room

A

MA

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29
Q

meaningful use requirements

A
  1. vitals
  2. smoking
  3. weight
  4. height
  5. 1st degree family history (or “no pertinent F/Hx)
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30
Q

name of EMR system

A

allscripts

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31
Q

sections of chart

A 
SOAP: 
S: HPI (story + context of chief complaint), ROS, Past history
O: PE (provider's objective findings)
A: diagnosis
P: Tx + F/U
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32
Q

Where to document: patient complaint

A

HPI or ROS

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33
Q

Where to document: past Dx or surgery

A

Past history (includes family history)

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34
Q

Where to document: physician’s observations

A

PE

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35
Q

Where to document: study

A

Results

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36
Q

Where to document: current Dx

A

Assessment

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37
Q

Where to document: CBC

A

Results, A&P

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38
Q

Where to document: EKG

A

Results, A&P

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39
Q

Where to document: “pt came in for CP”

A

HPI, ROS

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40
Q

Where to document: “stubbed his toe last year”

A

ROS

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41
Q

Where to document: “no acute distress”

A

PE

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42
Q

Where to document: HTN for many years

A

Past history, HPI

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43
Q

Where to document: tenderness in ABD

A

PE

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44
Q

Where to document: pt mother has heart disease

A

famHx = Past history

45
Q

Where to document: Dx is upper respiratory infection

A

A&P

46
Q

Where to document: will be prescribed meds

A

A&P

47
Q

Who enters allergies

A

MA, nurse (not scribe)

48
Q

Meds to pay attn to

A

Past meds, any supplements that relate to current health issues.

49
Q

“allergy” definition

A

anything that causes a rash, swelling, or difficulty breathing

50
Q

high cholesterol

A

hyperlipidemia (HLD)

51
Q

thyroid problem

A

hyperthyroidism / hyper

52
Q

heart disease

A

CAD

53
Q

heart attack

A

MI or CAD

54
Q

heart failure

A

CHF

55
Q

irregular heartbeat

A

A-fib

56
Q

asthma

A

asthma

57
Q

emphysema / chronic bronchitis

A

COPD

58
Q

pneumonia

A

PNA

59
Q

reflux

A

GERD (esophageal RD)

60
Q

pancreatitis

A

pancreatitis

61
Q

diverticulitis

A

diverticulitis

62
Q

irritable bowel

A

IBS

63
Q

bladder infection

A

UTI

64
Q

dialysis

A

CRF

65
Q

enlarged prostate

A

BPH (benign prostatic hypertrophy)

66
Q

GPA

A

G: # pregnancies
P: #deliveries / live births
A: #losses

67
Q

stroke

A

CVA

68
Q

mini-stroke

A

TIA

69
Q

brain bleed

A

CVA

70
Q

depression

A

depression

71
Q

i drink a lot

A

ETOH abuse / alcoholism

72
Q

blood clot in leg

A

LE DVT

73
Q

low back pain

A

chronic low back pain

74
Q

bulging disk

A

herniated disk or also DDD (degenerative disk)

75
Q

arthritis

A

OA (osteoarthritis) or sometimes RA (joints)

76
Q

join pain (chronic)

A

DJD (degenerative joint)

77
Q

weak / fragile bones

A

osteoporosis / osteopenia

78
Q

cancer

A

designate what kind … carcinoma or cancer (CA) or leukemia, etc.

79
Q

diabetes

A

DM (NIDDM / IDDM)

80
Q

-ectomy

A

removal surgery

81
Q

heart bypass surgery

A

CABG (with PMHx CAD)

82
Q

stents (heart)

A

coronary stents

83
Q

appendix

A

appendectomy

84
Q

gallbladder removal

A

cholecystectomy

85
Q

part of colon removed

A

partial colectomy

86
Q

bag to collect stool

A

colostomy

87
Q

stomach stapled

A

gastric bypass

88
Q

part of lung removed

A

lobectomy

89
Q

breast removal

A

mastectomy

90
Q

hole in neck

A

tracheostomy

91
Q

uterus removed

A

hysterectomy

92
Q

ovary removed

A

ooporectormy

93
Q

tubes tied

A

tubal ligation / vasectomy

94
Q

prostate removed

A

prostatectomy (TURP)

95
Q

neck artery cleaned

A

carotid endarterectomy

96
Q

brain surgery

A

craniotomy

97
Q

shunt (head)

A

ventriculoperitoneal

98
Q

PICC

A

PICC (peripherally inserted central catheter)

99
Q

joint repair

A

anthroplasty

100
Q

neck fused

A

C-spine

101
Q

back fused

A

L-spine

102
Q

younger onset = what genetic risk?

A

higher risk.

103
Q

parts of FHx

A

general (HTN, DM, CA), cardiac, pulmonary, GI, neuro, misc.

104
Q

Age that cardiac disease indicated higher risk

A

55 or younger

105
Q

social Hx

A 
tobacco
alcohol
illicit drugs
occupation
living circumstances
106
Q

age+ to report tobacco use (meaningful use)

A

13+

107
Q

drug administration routes

A

inhaled
oral
injected

108
Q

chronic alcoholism goes in which sections?

A

PMHx and SHx (chronic and abuse)

109
Q

SHx - PEDS type of items

A
  1. caretaker
  2. daycare / school
  3. brother / sisters
  4. 2nd hand smoke
  5. immunizations

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