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ScribeAmerica Training > OP 1: Welcome & Patient History > Flashcards

OP 1: Welcome & Patient History Flashcards

1
Q

Y/N? Your provider Dr. S, is tied up in a procedure so he asks you to tell the nurse to draw up 4mg of Morphine for the patient. Is this within the scope of a scribe?

A

No

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2
Q

Meets has been seen at your clinic, by Dr. P every 6 months for the past 2 yrs. She is here today for a routine appointment, but is seeing Dr. Polis’s Nurse Practitioner. Is Mara considered a new or established patient today?

A

Established

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3
Q

Rick made an appointment because he developed a rash a few days ago. Why type of visit is this?

A

Diagnostic visit

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4
Q

Karrie has an appointment for management of her diabetes. What type of visit is this?

A

Health Management visit

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5
Q

What is the correct order of the patient’s flow through the clinic?

A

Check in, History, Physical Exam, Order/Results, Check Out

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6
Q

If a patient has a prior diagnosis of hyperlipidemia, how would you classify this on their chart?

A

Medical History

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7
Q

If a patient has lungs that are clear to auscultation, how would you classify this on their chart?

A

Physical Exam

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8
Q

If a patient has their gallbladder removed, how would you classify this on their chart?

A

Surgical history

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9
Q

If a patient has a chest x ray showing pneumonia, how would you classify this on their chart?

A

Results

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10
Q

If a patient has a heart rate of 95bpm, how would you classify this on their chart?

A

Vital signs

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10
Q

If a patient says that they had a cough for three days, how would you classify this on their chart?

A

HPI/ROS

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11
Q

What is the layman’s term of High cholesterol?

A

Hyperlipidemia

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12
Q

What is the layman’s term of “I take shots of insulin”?

A

Diabetes Mellitus

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13
Q

What is the layman’s term of heart disease?

A

Coronary Artery Disease

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14
Q

What is the layman’s term of heart attack?

A

Myocardial Infarction

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15
Q

The patient reports a history of acid reflux, high blood pressure, and a small brain bleed that did not require surgery. What should you include in the PMHx?

A

GERD, HTN, Hemorrhagic CVA

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16
Q

What is an appendectomy?

A

Removal of the appendix

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17
Q

What is a Cholecystectomy?

A

Removal of the gallbladder

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18
Q

What is CABG?

A

Grafting an artery to work as a detour for blood around a blockage

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19
Q

What is a partial lobectomy?

A

A part of the lung was removed (likely due to lung CA)

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20
Q

At what age would a family member’s cardiac disease indicate an increased risk for similar heart disease in the patient?

A

Under 55

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21
Q

As a scribe, it is very important to update what in order for the provider to concentrate on the patient?

A

Electronic Health Record (EHR

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22
Q

As a scribe, when are we present?

A

During all data gathering including the patient conversation, physical exam, labs and imaging, and re-evaluations

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23
Q

A scribe can or cannot document the history, physical exam, results, procedures, and consults?

A

Can

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24
Q

A scribe can or cannot access and document laboratory results and radiology findings?

A

Can

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25
Q

A scribe can or cannot access and display x-rays for the physician to review

A

Can

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26
Q

A scribe can or cannot locate and obtain medical history, previous charts and past results

A

Can

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27
Q

A scribe can or cannot record physician interpretations of X-rays and ECGs

A

Can

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28
Q

A scribe can or cannot touch patients

A

Cannot

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29
Q

A scribe can or cannot write orders or prescriptions

A

A scribe can or cannot

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30
Q

A scribe can or cannot give verbal orders

A

Cannot

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31
Q

A scribe can or cannot sign or authenticate any chart or record (on behalf of the provider)

A

Cannot

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32
Q

A scribe can or cannot handle bodily fluids or specimens

A

A scribe can or cannot

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33
Q

What is a chief complaint?

A

The main reason for a patient’s outpatient visit

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34
Q

What is an EMR/EHR?

A

Electronic medical record/electronic health record

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35
Q

What is Subjective?

A

Feeling

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36
Q

What is Objective?

A

Factual finding from the provider

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37
Q

What is pain?

A

Patient’s feeling of discomfort

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38
Q

What is tenderness?

A

Doctor’s finding of reproducible pain

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39
Q

What is acute?

A

New onset, likely concerning

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40
Q

What is chronic?

A

Long-standing, not a direct concern

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41
Q

A patient has never been seen at the clinic, or was seen greater than 3 yrs. Ago, no previous records, longer visit, and a detailed chart. How would you classify them?

A

New

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42
Q

If a patient had been seen at the clinic (by any provider) within the last 3 yrs., previous records available, shorter visit, and a concise chart, how would you classify them?

A

Established

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43
Q

What type of visit occurs when there is a new problem, a chief complaint: new symptom, and a goal is to determine the cause of the problem and appropriate treatment?

A

Diagnostic

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44
Q

What type of visit is a check-up, the chief complaint: routine physical or management of chronic problem (s), and the goal is preventative care and/or assessing progress of ongoing medical problems?

A

Health Management

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45
Q

In regards to vital signs, what is the abbreviation of Heart Rate (bpm)?

A

HR

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46
Q

In regards to vital signs, what is the abbreviation of Blood Pressure?

A

BP (mmHg)

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47
Q

In regards to vital signs, what is the abbreviation of Respiratory Rate?

A

RR

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48
Q

In regards to vital signs, what is the abbreviation of Temperature?

A

T (C or F)

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49
Q

In regards to vital signs, what is the abbreviation of Oxygen Saturation?

A

SaO2 (%)

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50
Q

At check in , the Nurse or MA will do an assessment of what?

A

Chief Complaint (CC), Diagnostic vs. Health Management, Vital Signs, Height, Weight, Smoking status, and a review of allergies and medications

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51
Q

Before a patient enters a room upon check in, the provider will review what of the patient’s medical records?

A

Assessment & plan from the previous visit and Labs and/or imaging results

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52
Q

When the physician is doing the History & Physical (H&P), what will they be reviewing?

A

History of Present Illness (HPI), Review of Systems (ROS), Past History, Physical Exam (PE). Possibly a DDx if it is a diagnostic visit.

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53
Q

What are the different orders a physician might give?

A

Laboratory studies, imaging studies and procedures

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54
Q

In regards to Physician: Orders, What are the different laboratory studies?

A

Blood work, urinalysis, microscopy, cultures

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55
Q

In regards to Physician: Orders, What are the different imaging studies?

A

EKG, X-Ray, CT, and ultrasound

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56
Q

In regards to Physician: Orders, what are the procedures?

A

Sutures, join reduction, splints

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57
Q

In regards to Physician: Orders, when do results come back?

A

In a few days or during the visit which is rare.

58
Q

What do you document in the assessment of a physician?

A

The list of current diagnoses and the summary of the visit

59
Q

What do you document for the treatment plan from a physician?

A

Instructions for lifestyle changes, medications, and follow-up

60
Q

At check-out, what would you have to document?

A

If the patient was sent home vs. the EF and patient education provided.

61
Q

What is SOAP?

A

Subjective Complaints, Objective Evaluation, Assessment, and Plan

62
Q

In regards to SOAP, What are the subjective complaints?

A

History of Present Illness (HPI) & Review of Systems (ROS)

63
Q

What is the History of Present Illness? Also, what is their abbreviation?

A

The story and context of the chief complaint. (HPI)

64
Q

What is the Review of Systems? What is their abbreviation?

A

A head-to-toe list of positive and negatives. (ROS)

65
Q

What is in between the S & O in SOAP?

A

Patient History

66
Q

In regards to SOAP, what does the past history consist of?

A

Medical, Surgical, Social, and Family

67
Q

In regards to SOAP, Objective evaluation consists of?

A

Physical Examination (PE) and Orders & Results

68
Q

In regards to objective evaluation, what is Physical Examination and what is their abbreviation?

A

The physician’s objective findings. (PE)

69
Q

In regards to SOAP, what is the assessment?

A

Current diagnosis.

70
Q

In regards to SOAP, what is the plan?

A

Treatment plan & follow up

71
Q

Where do you document a patient complaint?

A

HPI or ROS (Subject Complaints)

72
Q

Where do you document for past diagnoses/surgeries?

A

Past History

73
Q

Where do you document for Physician’s observations?

A

Physical Exam (Objective Evaluation)

74
Q

Where do you document for labs, imaging, and studies?

A

Results (Objective Evaluation)

75
Q

Where do you document for current diagnoses?

A

Assessment

76
Q

Where do you document the treatment plan?

A

Plan

77
Q

What are the 3 things that you need to know about each disease?

A

The layman’s term, medical term, and the abbreviation

78
Q

As a scribe, what is layman’s term?

A

What the patient will likely call the disease

79
Q

As a scribe, what is the medical term?

A

What the scribe/provider will document

80
Q

When the patient says High Blood pressure, what will you write? What is the abbreviation?

A

Hypertension (HTN)

81
Q

When he patient says high cholesterol, what will you write? What is the abbreviation?

A

Hyperlipidemia (HLD)

82
Q

When a patient says Diabetes, what will you write? What is the abbreviation?

A

Diabetes Mellitus (DM)

83
Q

When a patient says, “I only take pills for my diabetes”. What will you write? What is the abbreviation?

A

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

84
Q

When a patient says, “I take shots (insulin) for my diabetes”, what do you write? What is the abbreviation?

A

Insulin Dependent Diabetes Mellitus (IDDM)

85
Q

When a patient says, “heart disease”, what will you write? What is the abbreviation?

A

Coronary Artery Disease (CAD)

86
Q

When a patient says, “Heart attack”, what will you write? What is the abbreviation?

A

Myocardial Infarction (MI) & CAD

87
Q

When a patient says,”Heart failure”, what do you write? What is the abbreviation?

A

Congestive heart failure (CHF)

88
Q

When a patient says, “irregular heartbeat”, you should write?

A

Arrhythmia

89
Q

When a patient says, “Emphysema or Chronic Bronchitis”, you should write? What is the abbreviation?

A

Chronic Obstructive Pulmonary Disease (COPD)

90
Q

When a patient says, “blood clot in lung”, you should write? What is the abbreviation?

A

Pulmonary embolism (PE)

91
Q

When a patient says, “Pneumonia or lung infection”, you should write? What is the abbreviation?

A

Pneumonia (PNA)

92
Q

When a patient says, “reflux”, you should write? What is the abbreviation?

A

Gastroesophageal Reflux Disease (GERD)

93
Q

When a patient says, “Ulcers”, you should write? What is the abbreviation?

A

Gastric Ulcer or Peptic Ulcer Disease (PUD)

94
Q

When a patient says, “Irritable Bowel”, you should write? What is the abbreviation?

A

Irritable Bowel Syndrome (IBS)

95
Q

When a patient says, “bladder infection”, you should write? What is the abbreviation?

A

Urinary Tract Infection (UTI)

96
Q

When a patient says, “Kidney infection”, you should write?

A

Pyelonephritis

97
Q

When a patient says, “I’m on dialysis”, you should write? What is the abbreviation?

A

Chronic Kidney Disease (CKD) on dialysis

98
Q

When a patient says, “enlarged prostate”, what should you write? What is the abbreviation?

A

Benign prostatic hypertrophy (BPH)

99
Q

When a patient says, “Stroke”, you should write? What is the abbreviation?

A

Cerebrovacular Accident (CVA)

100
Q

When a patient says, “Blood clot in brain”, what do you write?

A

Ischemic CVA

101
Q

When a patient says, “Brain Bleed”, you should write?

A

Hemorrhagic CVA

102
Q

When a patient says, “mini stroke”, you should write? What is the abbreviation?

A

Transient Ischemic Attack (TIA)

103
Q

When a patient says, “blood clot in my leg”, you should write? What is the abbreviation?

A

Deep vein thrombosis (DVT)

104
Q

When a patient says, “Bulge in my aorta”, what should you write?

A

Aortic Aneurysm

105
Q

When a patient says, “Bad blood flow in my legs”, what should you write? What is the abbreviation?

A

Peripheral Vascular Disease (PVD)

106
Q

When a patient says, “Cancer”, you should write? What is the abbreviation?

A

Cancer or Carcinoma (CA)

107
Q

When a patient says, “spread to my…”, you should write?

A

With metastasis to the…

108
Q

When a patient says, “chemo”, you should write?

A

Chemotherapy

109
Q

When a patient says, “Radiation”, you should write?

A

Radiation therapy

110
Q

When a patient says, “they cut it out”, you should write?

A

Status-post surgical resection

111
Q

When a patient says, “it’s gone”, you should write?

A

In remission

112
Q

If it is not a true allergy, what else might it be?

A

An adverse reaction

113
Q

What should we pay attention to when reviewed by the doctor?

A

Allergies

114
Q

What should we catch if it is part of the story that brought the patient to the clinic?

A

Specific home medications

115
Q

When a patient says, “tonsils removed”, you should write?

A

Tonsillectomy

116
Q

When a patient says, “Adenoids removed”, you should write?

A

Adenoidectomy

117
Q

When a patient says, “Neck arteries cleaned”, what should you write?

A

Carotid endarterectomy

118
Q

When a patient says, “leg amputated”, what should you write? What is the abbreviation?

A

Above knee Amputation (AKA) Below Knee Amputation (BKA)

119
Q

When a patient says, “joint repair”, what should you write?

A

Arthroplasty

120
Q

When a patient says, “Balloon in my heart”, what should you write?

A

Angioplasty & PMHx CAD

121
Q

When a patient says, “Stents in my heart”, what should you write?

A

Coronary Stents & PMHx CAD

122
Q

When a patient says, “heart bypass”, you should write?

A

Coronary Artery Bypass Graft (CABG) & PMHx CAD

123
Q

When a patient says, “Breast removal”, you should write?

A

Mastectomy

124
Q

When a patient says, “part of my lung removed”, you should write?

A

Partial lobectomy

125
Q

When a patient says, “appendix removed”, you should write?

A

Appendectomy

126
Q

When a patient says, “Gallbladder removed”, you should write?

A

Cholecystectomy

127
Q

When a patient says, “part of my colon removed”, what should you write?

A

Partial colectomy

128
Q

When a patient says, “spleen removed”, you should write?

A

Splenectomy

129
Q

When a patient says, “Kidney removed”, you should write?

A

Nephrectomy

130
Q

When a patient says, “uterus removed”, you should write?

A

Hysterectomy

131
Q

When a patient says, “ovary removed”, you should write?

A

Oophorectomy

132
Q

What is the abbreviation of Family History?

A

FHx

133
Q

What does FHx include?

A

Any medical condition present in the patient’s blood relatives

134
Q

What age is of higher genetic risk?

A

Under 55.

135
Q

If the pt. Is of older age of unset is likely more due to what?

A

Environment than genetics

136
Q

Why is the age of onset for each disease very important to family history?

A

It helps determine the genetic risk factor

137
Q

What is the abbreviation of Social History?

A

SHx

138
Q

What is considered to be SHx?

A

Alcohol Use, Tobacco Use/Vaping, Drug Use, Occupation, and Living Circumstances

139
Q

In regards to SHx, what should you note when a patient does Tobacco Use/Vaping?

A

Pack per day (PPD)

140
Q

In regards to SHx, what should be charted in Drug Use?

A

What substance? Route of administration? Date of last use/ how often?

141
Q

In regards to SHx, what should you chart when it comes to occupation?

A

Manual labor, stress, night shifts, etc. exposure to chemicals, fumes, irritants

142
Q

In regards to SHx, what should you document for living circumstances?

A

Alone, Lives with family, nursing home or assisted living, hospice, homeless

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