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ScribeAmerica, Outpatient, Lesson 1 Exam (100% Guaranteed Pass) LATEST UPDATE.
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ScribeAmerica, Outpatient, Lesson 1 Exam (100% Guaranteed Pass) LATEST UPDATE.
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ScribeAmerica, Outpatient, Lesson 1 Exam(100% Guaranteed Pass) LATEST UPDATE
1.1 What is the role of each person in the clinic and the scope of scribe? Mid-Level? Nurse/MA?
Receptionist? Scribe?
MID-LEVEL: (PA/NP) works under the supervision of the physician to diagnose and treat patients
NURSE/MA: records medical histories and sx; monitors the patient; completes meaningful use
requirements; administers medication; assists with procedures
RECEPTIONIST: answers phones; schedules patient appointments; answers patient questions; provides
patient with summary of visit with instructions from provider at checkout; organizes the patients
paperwork;
SCRIBE: documents the patients visit on behalf of they physician.
1.2 What is the difference between a new and established patient?
NEW PATIENT: no previous records, longer visits, detailed chart (if not seen for 3 yrs or more)
ESTABLISHED PT: previous records available, shorter visits, concise cha
1.3 How does a patient move through an outpatient clinic visit?
check-in, physician eval, orders & results, assessment and plan, check-out
1.4 How are patient visits documented?
using S.O.A.P
1.5 How do scribes document past medical history?
, in Past History- PMedicalHx
1.6 How do scribes document past surgical history?
in Past History - PSurgical Hx
1.7 How do scribes document family history?
in Past History - FamilyMHx
1.8 How do scribes document social history?
in Past History - SocialMHx
1.0 Subjective
feeling (CC, HPI, ROS)
1.0 Objective
fact (PE)
1.0 Benign
normal, nothing of concern
1.0 Acute
new onset
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