Week 1 Training

Question 1

subjective vs objective

Answer 1

feeling vs fact, patient vs doctor

Question 2

pain vs tenderness

Answer 2

patients feeling vs physician’s assessment

Question 3

bengn

Answer 3

normal nothing of concern

Question 4

acute vs chronic

Answer 4

new onset vs long standing

Question 5

baseline

Answer 5

an individual’s normal state of being

Question 6

auscultation

Answer 6

listening with stethoscope

Question 7

palpation

Answer 7

the act of pressing on the area by the physcian

Question 8

inpatient

Answer 8

admitted to the hospital overnight

Question 9

outpatient

Answer 9

seen and sent home the same day

Question 10

chief complaint

Answer 10

the main reason for the patients visit

Question 11

medical decision making

Answer 11

the physician’s thought process

Question 12

midlevel provider

Answer 12

nurse practitioner or physicians assistant that works under the supervision of the physician to diagnose and treat patients

Question 13

nurse or medical assistant

Answer 13

records medical histories and symptoms monitors the patient, administers medications and ssists with procedures

Question 14

receptionist

Answer 14

answeres phone calls shcedules appointments answeres patient questions provides patiens with summary of the vistit and written instuctions from the provider at check out and organizes the patients paper work

Question 15

scribe

Answer 15

documents the patients visit on the behalf of the physician, access and document lab results and radiology findings, locate and optain PMHx preivious charts and recent studies, record physician interpretations of x rays and EKGs
cannot give orders or touch patients in anyway, participate in care in a way that would effect outcome, authenticate chart or handle specimen

Question 16

Clinic flow

Answer 16

check in physician evaluation, orders and results, assesment and plan, check out
this stuff follows the format of the chart

Question 17

H & P

Answer 17

history and physical- part of physician eval. in clinic flow

Question 18

ARIA

Answer 18

clinics documentation system- electronic medical record (EMR)

Question 19

SOAP

Answer 19

Subjective, Objective, Assessment and Plan:
Subjective- history of present illness(HPI) and review of systems (ROS)- patient complaint, past history/diagnosis or surgery
Objective- Physical exam (PE) and orders and results- physicians observations and studies
Assessment - diagnoses- short description of progress since last visit
Plan- treatment and follow up for each diagnosis

Question 20

importance of FHx

Answer 20

history of onset in family helps to determine the genetic risk of a disease for a patient
if the onset of the disease was after 50 y/o the disease is likely due to the environment rather than genetic risk

Question 21

importance of SHx

Answer 21

this helps determine risks for patients and recommended treatment b/c your aren’t gonna give someone debilitating chemo if they live alone
Tobacco use, alcohol use, illicit drug use, occupation, living circumstance

Question 22

chief complaint

Answer 22

primary reason patient came in.
must make sure it is detailed so it can be billed properly
ex check up= maintenance visit
follow up= management evaluation
lab results= discuss treatment options(based on results)
medication refill= evaluation of medication management

Question 23

History of present illness

Answer 23

HPI is the story of the chief complaint so this will be in complete sentence form with proper punctuation and capitalization and approved abbreviations
-symptoms and events that led to the visit that are directly related to the chief complaint
-subjective and is followed throu the rest of chart
-list the complaints of the chief one in the ROS as well
-document their previous symptoms related to this complaint
document any prior testing that is related todays complaint
- structured chronologically (for us)

Question 24

8 elements of the HPI

Answer 24

element- description
onset- beginning
timing- constant, intermittent or waxing and waning
location
quality- sharp dull aching cramping
severity- mild severe 1-10
modifying factors- what makes it feel worse or better
associated Sx- accompanying symptoms as well as pertinent negatives
context- other important stuff

Question 25

intermittent

Answer 25

comes and goes

Question 26

waxing and waning

Answer 26

always present but changing in intensity

Question 27

modifying factor

Answer 27

something that makes a symptom better or worse

Question 28

exacerbate

Answer 28

to make worse

Question 29

Chronological structure of HPI

Answer 29

important for patients with complex stories
ordered by age and sex, prelevant PHx (new patients), previous evaluation, previous treatment, current complaints, elements of first complaint, elements of second complaint, context

Question 30

Review of Systems

Answer 30

ROS- head to toe check list of patients body systems- not a story, include details from chief complaint as well

• list of positives and negative
• must not contradict HPI
• usually receive info thro patient questionnaires, if something seems obviously important and the physician doesn’t cover it subtly point it out

Question 31

cachectic

Answer 31

emaciated, malnourished, boney

Question 32

objective

Answer 32

Vital signs, physical exam, orders and results

Question 33

vital signs

Answer 33

blood pressure, heart rate, respiratory rate, temperature, oxygen saturation

• check to make sure they are documented (nurse usually does it)
• especially important for fever complaints and management of HTN or COPD

Question 34

physical exam

Answer 34

Talking and looking does most of it- general, eyes, pulmonary, skin, neurological, psychiatric
Basic- looking at patient (general apperance, eyes and skin) , auscultating the heart and lungs (heart rate rythem murmer and breath sounds), palpating the abdomen and legs (abdominal tenderness, softness, and edema, distal pulses, tenderness)
Detailed- *neurological exam, *gait assessment, detailed eye exam, hearing/vision assessment, GYN exam

Question 35

what systems does the ROS cover?

Answer 35

Goes through: Constitutional (fever weight loss sweats), eyes, E/N/T, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary/ skin, neurological, psychiatric, endocrine, hematologic/lymph, immunologic

Question 36

follow up

Answer 36

Establishment or maintenance of consistent contract with health care providers in order to address an ongoing health concern

Question 37

Subq

Answer 37

Subcutaneous- medication injected under the skin

Question 38

Prognosis

Answer 38

Forecast of the likely code of a disease or ailment

Question 39

What should the assessment include?

Answer 39

diagnosis and summary of visit

Ours in list form

Question 40

What should be in the results summary?

Answer 40

only results that are new since last visit and are related/ relevant to the diagnosis
Include name of test, result, why ordered, date

Question 41

What is in the plan section and what should be included?

Answer 41

outlines how the doc will treat or monitor the patient

At least one bullet for each diagnosis with the final line always being for follow up