Medical Scribe Questions with Correct Answers

Acute vs Chronic Correct Answer new onset, to be of concern vs. long standing, not as concerning Seen and sent home the same day Correct Answer outpatient Chief complaint is... Correct Answer the main reason for the patient's visit A set of government mandated criteria that must be obtained for every patient Correct Answer meaningful use Baseline Correct Answer An individual's normal state of being Tasks you CAN complete as a scribe Correct Answer - document the history and physical exam while the physician performs them - pend orders upon instruction of the provider - locate previous results to show provider Scribes cannot... Correct Answer -touch patients -write orders or prescriptions -give verbal orders -partake in any activity that may affect patient health or outcome -sign or authenticate any chart or record -handle bodily fluids or specimens You are working at a facility where the nurse completes the ROS for the patient. However, when you enter the room with the doctor, you notice that one of the patient's answers contradicts the ROS recorded by the nurse. What should you do? Correct Answer Wait until you exit the patient room and notify the doctor of the discrepancy A SOAP note for an established patient will be ________ than the note for a new patient Correct Answer shorter A patient made an appointment because she developed a rash a few days ago. What type of visit would this be? Correct Answer A Diagnostic visist Why is documenting a thorough HPI important? Correct Answer HPI serves as the basis for the work up that follows Elements of the HPI Correct Answer Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx, Context