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
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
3
Q
Rick made an appointment because he developed a rash a few days ago. Why type of visit is this?
A
Diagnostic visit
4
Q
Karrie has an appointment for management of her diabetes. What type of visit is this?
A
Health Management visit
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
6
Q
If a patient has a prior diagnosis of hyperlipidemia, how would you classify this on their chart?
A
Medical History
7
Q
If a patient has lungs that are clear to auscultation, how would you classify this on their chart?
A
Physical Exam
8
Q
If a patient has their gallbladder removed, how would you classify this on their chart?
A
Surgical history
9
Q
If a patient has a chest x ray showing pneumonia, how would you classify this on their chart?
A
Results
10
Q
If a patient has a heart rate of 95bpm, how would you classify this on their chart?
A
Vital signs
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
11
Q
What is the layman’s term of High cholesterol?
A
Hyperlipidemia
12
Q
What is the layman’s term of “I take shots of insulin”?
A
Diabetes Mellitus
13
Q
What is the layman’s term of heart disease?
A
Coronary Artery Disease
14
Q
What is the layman’s term of heart attack?
A
Myocardial Infarction
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
16
Q
What is an appendectomy?
A
Removal of the appendix
17
Q
What is a Cholecystectomy?
A
Removal of the gallbladder
18
Q
What is CABG?
A
Grafting an artery to work as a detour for blood around a blockage
19
Q
What is a partial lobectomy?
A
A part of the lung was removed (likely due to lung CA)
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
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
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
23
Q
A scribe can or cannot document the history, physical exam, results, procedures, and consults?
A
Can
24
A scribe can or cannot access and document laboratory results and radiology findings?
Can
25
A scribe can or cannot access and display x-rays for the physician to review
Can
26
A scribe can or cannot locate and obtain medical history, previous charts and past results
Can
27
A scribe can or cannot record physician interpretations of X-rays and ECGs
Can
28
A scribe can or cannot touch patients
Cannot
29
A scribe can or cannot write orders or prescriptions
A scribe can or cannot
30
A scribe can or cannot give verbal orders
Cannot
31
A scribe can or cannot sign or authenticate any chart or record (on behalf of the provider)
Cannot
32
A scribe can or cannot handle bodily fluids or specimens
A scribe can or cannot
33
What is a chief complaint?
The main reason for a patient’s outpatient visit
34
What is an EMR/EHR?
Electronic medical record/electronic health record
35
What is Subjective?
Feeling
36
What is Objective?
Factual finding from the provider
37
What is pain?
Patient’s feeling of discomfort
38
What is tenderness?
Doctor’s finding of reproducible pain
39
What is acute?
New onset, likely concerning
40
What is chronic?
Long-standing, not a direct concern
41
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?
New
42
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?
Established
43
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?
Diagnostic
44
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?
Health Management
45
In regards to vital signs, what is the abbreviation of Heart Rate (bpm)?
HR
46
In regards to vital signs, what is the abbreviation of Blood Pressure?
BP (mmHg)
47
In regards to vital signs, what is the abbreviation of Respiratory Rate?
RR
48
In regards to vital signs, what is the abbreviation of Temperature?
T (C or F)
49
In regards to vital signs, what is the abbreviation of Oxygen Saturation?
SaO2 (%)
50
At check in , the Nurse or MA will do an assessment of what?
Chief Complaint (CC), Diagnostic vs. Health Management, Vital Signs, Height, Weight, Smoking status, and a review of allergies and medications
51
Before a patient enters a room upon check in, the provider will review what of the patient’s medical records?
Assessment & plan from the previous visit and Labs and/or imaging results
52
When the physician is doing the History & Physical (H&P), what will they be reviewing?
History of Present Illness (HPI), Review of Systems (ROS), Past History, Physical Exam (PE). Possibly a DDx if it is a diagnostic visit.
53
What are the different orders a physician might give?
Laboratory studies, imaging studies and procedures
54
In regards to Physician: Orders, What are the different laboratory studies?
Blood work, urinalysis, microscopy, cultures
55
In regards to Physician: Orders, What are the different imaging studies?
EKG, X-Ray, CT, and ultrasound
56
In regards to Physician: Orders, what are the procedures?
Sutures, join reduction, splints
57
In regards to Physician: Orders, when do results come back?
In a few days or during the visit which is rare.
58
What do you document in the assessment of a physician?
The list of current diagnoses and the summary of the visit
59
What do you document for the treatment plan from a physician?
Instructions for lifestyle changes, medications, and follow-up
60
At check-out, what would you have to document?
If the patient was sent home vs. the EF and patient education provided.
61
What is SOAP?
Subjective Complaints, Objective Evaluation, Assessment, and Plan
62
In regards to SOAP, What are the subjective complaints?
History of Present Illness (HPI) & Review of Systems (ROS)
63
What is the History of Present Illness? Also, what is their abbreviation?
The story and context of the chief complaint. (HPI)
64
What is the Review of Systems? What is their abbreviation?
A head-to-toe list of positive and negatives. (ROS)
65
What is in between the S & O in SOAP?
Patient History
66
In regards to SOAP, what does the past history consist of?
Medical, Surgical, Social, and Family
67
In regards to SOAP, Objective evaluation consists of?
Physical Examination (PE) and Orders & Results
68
In regards to objective evaluation, what is Physical Examination and what is their abbreviation?
The physician’s objective findings. (PE)
69
In regards to SOAP, what is the assessment?
Current diagnosis.
70
In regards to SOAP, what is the plan?
Treatment plan & follow up
71
Where do you document a patient complaint?
HPI or ROS (Subject Complaints)
72
Where do you document for past diagnoses/surgeries?
Past History
73
Where do you document for Physician’s observations?
Physical Exam (Objective Evaluation)
74
Where do you document for labs, imaging, and studies?
Results (Objective Evaluation)
75
Where do you document for current diagnoses?
Assessment
76
Where do you document the treatment plan?
Plan
77
What are the 3 things that you need to know about each disease?
The layman’s term, medical term, and the abbreviation
78
As a scribe, what is layman’s term?
What the patient will likely call the disease
79
As a scribe, what is the medical term?
What the scribe/provider will document
80
When the patient says High Blood pressure, what will you write? What is the abbreviation?
Hypertension (HTN)
81
When he patient says high cholesterol, what will you write? What is the abbreviation?
Hyperlipidemia (HLD)
82
When a patient says Diabetes, what will you write? What is the abbreviation?
Diabetes Mellitus (DM)
83
When a patient says, “I only take pills for my diabetes”. What will you write? What is the abbreviation?
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
84
When a patient says, “I take shots (insulin) for my diabetes”, what do you write? What is the abbreviation?
Insulin Dependent Diabetes Mellitus (IDDM)
85
When a patient says, “heart disease”, what will you write? What is the abbreviation?
Coronary Artery Disease (CAD)
86
When a patient says, “Heart attack”, what will you write? What is the abbreviation?
Myocardial Infarction (MI) & CAD
87
When a patient says,”Heart failure”, what do you write? What is the abbreviation?
Congestive heart failure (CHF)
88
When a patient says, “irregular heartbeat”, you should write?
Arrhythmia
89
When a patient says, “Emphysema or Chronic Bronchitis”, you should write? What is the abbreviation?
Chronic Obstructive Pulmonary Disease (COPD)
90
When a patient says, “blood clot in lung”, you should write? What is the abbreviation?
Pulmonary embolism (PE)
91
When a patient says, “Pneumonia or lung infection”, you should write? What is the abbreviation?
Pneumonia (PNA)
92
When a patient says, “reflux”, you should write? What is the abbreviation?
Gastroesophageal Reflux Disease (GERD)
93
When a patient says, “Ulcers”, you should write? What is the abbreviation?
Gastric Ulcer or Peptic Ulcer Disease (PUD)
94
When a patient says, “Irritable Bowel”, you should write? What is the abbreviation?
Irritable Bowel Syndrome (IBS)
95
When a patient says, “bladder infection”, you should write? What is the abbreviation?
Urinary Tract Infection (UTI)
96
When a patient says, “Kidney infection”, you should write?
Pyelonephritis
97
When a patient says, “I’m on dialysis”, you should write? What is the abbreviation?
Chronic Kidney Disease (CKD) on dialysis
98
When a patient says, “enlarged prostate”, what should you write? What is the abbreviation?
Benign prostatic hypertrophy (BPH)
99
When a patient says, “Stroke”, you should write? What is the abbreviation?
Cerebrovacular Accident (CVA)
100
When a patient says, “Blood clot in brain”, what do you write?
Ischemic CVA
101
When a patient says, “Brain Bleed”, you should write?
Hemorrhagic CVA
102
When a patient says, “mini stroke”, you should write? What is the abbreviation?
Transient Ischemic Attack (TIA)
103
When a patient says, “blood clot in my leg”, you should write? What is the abbreviation?
Deep vein thrombosis (DVT)
104
When a patient says, “Bulge in my aorta”, what should you write?
Aortic Aneurysm
105
When a patient says, “Bad blood flow in my legs”, what should you write? What is the abbreviation?
Peripheral Vascular Disease (PVD)
106
When a patient says, “Cancer”, you should write? What is the abbreviation?
Cancer or Carcinoma (CA)
107
When a patient says, “spread to my…”, you should write?
With metastasis to the…
108
When a patient says, “chemo”, you should write?
Chemotherapy
109
When a patient says, “Radiation”, you should write?
Radiation therapy
110
When a patient says, “they cut it out”, you should write?
Status-post surgical resection
111
When a patient says, “it’s gone”, you should write?
In remission
112
If it is not a true allergy, what else might it be?
An adverse reaction
113
What should we pay attention to when reviewed by the doctor?
Allergies
114
What should we catch if it is part of the story that brought the patient to the clinic?
Specific home medications
115
When a patient says, “tonsils removed”, you should write?
Tonsillectomy
116
When a patient says, “Adenoids removed”, you should write?
Adenoidectomy
117
When a patient says, “Neck arteries cleaned”, what should you write?
Carotid endarterectomy
118
When a patient says, “leg amputated”, what should you write? What is the abbreviation?
Above knee Amputation (AKA) Below Knee Amputation (BKA)
119
When a patient says, “joint repair”, what should you write?
Arthroplasty
120
When a patient says, “Balloon in my heart”, what should you write?
Angioplasty & PMHx CAD
121
When a patient says, “Stents in my heart”, what should you write?
Coronary Stents & PMHx CAD
122
When a patient says, “heart bypass”, you should write?
Coronary Artery Bypass Graft (CABG) & PMHx CAD
123
When a patient says, “Breast removal”, you should write?
Mastectomy
124
When a patient says, “part of my lung removed”, you should write?
Partial lobectomy
125
When a patient says, “appendix removed”, you should write?
Appendectomy
126
When a patient says, “Gallbladder removed”, you should write?
Cholecystectomy
127
When a patient says, “part of my colon removed”, what should you write?
Partial colectomy
128
When a patient says, “spleen removed”, you should write?
Splenectomy
129
When a patient says, “Kidney removed”, you should write?
Nephrectomy
130
When a patient says, “uterus removed”, you should write?
Hysterectomy
131
When a patient says, “ovary removed”, you should write?
Oophorectomy
132
What is the abbreviation of Family History?
FHx
133
What does FHx include?
Any medical condition present in the patient’s blood relatives
134
What age is of higher genetic risk?
Under 55.
135
If the pt. Is of older age of unset is likely more due to what?
Environment than genetics
136
Why is the age of onset for each disease very important to family history?
It helps determine the genetic risk factor
137
What is the abbreviation of Social History?
SHx
138
What is considered to be SHx?
Alcohol Use, Tobacco Use/Vaping, Drug Use, Occupation, and Living Circumstances
139
In regards to SHx, what should you note when a patient does Tobacco Use/Vaping?
Pack per day (PPD)
140
In regards to SHx, what should be charted in Drug Use?
What substance? Route of administration? Date of last use/ how often?
141
In regards to SHx, what should you chart when it comes to occupation?
Manual labor, stress, night shifts, etc. exposure to chemicals, fumes, irritants
142
In regards to SHx, what should you document for living circumstances?
Alone, Lives with family, nursing home or assisted living, hospice, homeless
