Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

ScribeAmerica Training > Week 1 - Patient Health History > Flashcards

Week 1 - Patient Health History Flashcards

1
Q

Give some examples of what is out of scope for scribes?

A

Touch patients

Write orders or prescriptions

Give verbal orders

Sign or authenticate any chart or record

Handle bodily fluids or specimens

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What do you call the main reason for the patient’s emergency visit?

A

Chief complaint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

EMR/EHR

A

Electronic medical record/electronic health record

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Difference between subjective and objective

A

Feelings from the patient

Factual findings from the provider

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Difference between pain and tenderness

A

Patient’s feeling of discomfort

Doctor’s finding of reproducible pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Difference between acute and chronic

A

New onset, likely concerning

Long-standing, not of direct concern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the emergency department flow?

A

Check In & Triage

History & Physical

Differential Diagnosis

Orders & Treatment

Medical Decision Making

Disposition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the main vital signs and their abbreviations?

A

(HR) Heart rate (bpm)
(BP) Blood pressure (mmHg)
(RR) Respiratory rate
T: Temperature (C or F)
SaO2: Oxygen Saturation (%)

Level of Acuity: 1 (High) to 5 (Low)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When does the scribes documentation begin?

A

The HPI and ROS (after the nurse assessment)

History of Present Illness and Review of Systems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What will the physician do with the H&P?

A

These leads to differential diagnoses (DDx)

The physician generaties a list of things that MAY be causing the patient’s subjective symptoms.

Then the doctor places orders to “rule out” each differential.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are types of lab studies the physician may order?

A

Blood work, urinalysis, microscopy, cultures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are types of imaging studies the physician may order?

A

EKG/ECG, X-Ray, CT, Ultrasound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are types of procedures the physician may order?

A

Sutures, joint reduction, splints

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are types of medications the physican may order?

A

Antiemetics, analgesics, vasodilators, diuretics, antibiotics.

Antiemetics are used to prevent or treat nausea and vomitting.

Analgesics are painkillers and pain medications aimed at redcucing pain.

Vasodilators are meds that open or dilate blood vessels especially in high blood pressure events.

Diuretics help rid body of water and sodium. This increase salt production of the liver, removing excess water from the blood, decreasing the amount of fluid flowing through your veins and arteries which reduces blood pressure.

Antibiotics are medicines that fight bacterial infections in people and animals.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What comes after the orders and treatment for the emergency department flow for a specific patient?

What comes after this?

A

The medical decision making (MDM) consists of the diagnosis or treatment plan. (discharged, admitted, trasnferred, left AMA (against medical advice), expired)

The disposition of the patient comes after the MDM.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What do the subjective complaints consist of?

What does the objective evaluation consist of?

A

HPI/ROS

Physical exam/Orders and Treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

PMHx The Most Common

high blood pressure

A

Hypertension (HTN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

PMHx The Most Common

high cholesterol

A

Hyperlipidemia (HLD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

PMHx The Most Common

Diabetes

A

Diabetes Mellitus (DM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

PMHx The Most Common

I only take pills for my diabetes

A

Non-insulin dependent diabetes mellitus (NIDDM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

PMHx The Most Common

I take shots (insulin) for my diabetes

A

Insulin dependent diabetes mellitus (IDDM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

PMHx Cardivascular

heart disease

A

Coronary Artery Disease (CAD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

PMHx Cardivascular

heart attack

A

Myocardial Infarction (MI) and CAD

24
Q

PMHx Cardivascular

heart failure

A

Congestive Heart Failure (CHF)

25
Q

PMHx Cardivascular

irregular heartbeat

A

Arrhythmia

26
Q

PMHx Pulmonary

asthma

A

Asthma

27
Q

PMHx Pulmonary

Emphysema or chronic bronchitis

A

Chronic Obstructive Pulmonary Disease (COPD)

28
Q

PMHx Pulmonary

Blood clot in lung

A

Pulmonary Embolism (PE)

29
Q

PMHx Pulmonary

Pneumonia

A

Pneumonia (PNA)

30
Q

PMHx Gastrointestinal

Reflux

A

Gastroesophageal Reflux Disease (GERD)

31
Q

PMHx Gastrointestinal

Ulcers

A

Gastric Ulcer or Peptic Ulcer Disease (PUD)

32
Q

PMHx Gastrointestinal

Pancreatitis

A

Pancreatitis

33
Q

PMHx Gastrointestinal

Hepatitis

A

Hepatitis

34
Q

PMHx Gastrointestinal

Irritable bowel

A

Irritable Bowel Syndrome (IBS)

35
Q

PMHx Genitourinary

Bladder infection

A

Urinary Tract Infection (UTI)

36
Q

PMHx Genitourinary

Kidney infection

A

Pyelonephritis

37
Q

PMHx Genitourinary

Kidney stones

A

Renal Calculi

38
Q

PMHx Genitourinary

I’m on dialysis

A

Chronic Kidney Disease (CKD) on dialysis

39
Q

PMHx Genitourinary

enlarged prostate

A

Benign Prostatic Hyperplasia (BPH)

40
Q

PMHx Gynecological

What is the convention for documentating past pregnancies, births, and abortions that you must be familiar with?

This is considered a pertinent part of PMHx for any female patient.

A

The convention is known as G: P: A:

  • Gravida “G” is the total number of times the patient has been pregnant
  • Para “P” is the number of pregnancies that resulted in viable births
  • Abortus “A” is the total number of miscarriages or elective abortions
41
Q

PMHx Vascular

Stroke

Blockage in the Brain

Brain bleed

A

Cerebrovascular Accident (CVA)

Ischemic CVA

Hemorrhagic CVA

42
Q

PMHx Vascular

“Mini stroke”

Blood clot in my leg

“Bulge in my aorta”

“Bad blood flow in my legs”

A

Transcient Ischemic Attack (TIA)

Deep vein thrombosis (DVT)

Aortic Aneurysm

Peripheral Vascular Disease (PVD)

43
Q

What do these abbreviations mean?

History information is not always relevant to the chief complaint, so we place all history infor in the PHx which includes PMHx, PSHx, SHx, and FHx

A

PHx = Past History sections
PMHx = Past Medical History
PSHx = Past Surgical History
SHx = Social History
PHx = Family History

44
Q

What does the following mean?

itis
osis
ectomy
nephr
chole
mast
hepa

A

itis is inflammation
osis is disease
ectomy is surgical removal
nephr is kidneys/renal (renal relates to the FUNCTION of kidneys)
chole is gallbladder
mast is breasts
hepa is liver

45
Q

Translate the following laymen speak of past surgical history:

Tonsils removed
Adenoids removed
Ear Tubes

A

Tonsillectomy
Adenoidectomy
Pressure Equalizer (P.E.) Tubes

46
Q

Translate the following laymen speak of past surgical history (PSHx):

“balloon in my heart”
“Stents in my heart”
Heart bypass
breast removal
Part of my lung removed

A

Angioplasty —> PMHx CAD
Coronary Stents —-> PMHx CAD
Coronary Artery Bypass Graft (CABG) —-> PMHx CAD
Masectomy
Partial Lobectomy

47
Q

Translate the following laymen speak of past surgical historys (PSHx) for the GI:

Appendix removed
Gallbladder removed
Part of my colon removed
Spleen removed
Kidney removed

A

appendectomy
cholecystectomy
partial colectomy
splenectomy
nephrectomy

48
Q

Translate the following laymen speak of past surgical historys (PSHx) for the GU:

Uterus removed
Ovary removed
Ovary and fallopian tube removed
Prostate removed

A

Hysterectomy
Oophorectomy
Salpingo-oophorectomy
Prostatectomy

49
Q

What does family history or FHx pertain to when determining genetic risk factors?

A

Parents and grandparents to include siblings.

50
Q

What is the age of onset for disease that means higher genetic risk?

A

Under 55

51
Q

What are some things that consist of Social history or SHx?

A

Tobacco/Alcohol/Drug Use

Occupation

Living Circumstances

52
Q

Why should you pay attention to medications?

A

It can tell you a lot about past medical history

53
Q

What is a true allergy to a medication defined as?

A

Medication that causes itching, swelling, difficulty breathing or rash.

Otherwise it is an “adverse reaction,” not a true allergy.

54
Q

Top 10 key things to document as a scribe! (No Answer)

A provider’s INVESTIGATION of ptx

  1. Reviewing external records (notes or summaries from other hospitals or EMS)
  2. Documenting independent historians (history obtained other than the pt)
  3. Capturing chronic illnesses (listing comorbidities, differential dx, risk assessments)

A provider’s ACTIONS

  1. When drugs require intensive monitoring (what medications given and when, including any follow up)
  2. Independent interpretations by your provider (live discussions with other providers about test results)
  3. Test interpretations discussed with external provider (live discussions with other providers about test results)

A provider’s CONSIDERATIONS

  1. Considerations of admission or escalation of care (why a pt was escalated to ICU or considered safe to go home)
  2. Considerations of diagnostic tests even if not done (considering one test over another and why it was done or not. Such as CT scans)
  3. Prescription medications given or considered (Documenting meds considered like antibiotics even if not given, and reason)
  4. If patient care is affected by social determinations (documenting if a plan of care was changed or determined because of social factors that may impact health.
A

No Answer

55
Q

Why is it so important to document everything?

A

To bill correctly, and for legal/historical reasons

ScribeAmerica Training (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions