Study Guide for ScribeAmerica Final Best Rated
Test Bank
Subjective - ANSWER-Feeling (patient)
Objective - ANSWER-Fact (provider)
Benign - ANSWER-Normal, nothing of concern
Acute - ANSWER-New onset
Chronic - ANSWER-Long-standing
Baseline - ANSWER-An individual's normal state of being
Auscultation - ANSWER-Listening with a stethoscope
Palpation - ANSWER-The act of pressing on an area (by the physician)
Inpatient - ANSWER-Admitted to the hospital overnight
Outpatient - ANSWER-Seen and sent home the same day
Chief Complaint (CC) - ANSWER-The main reason for the patient's visit
Medical Decision Making (MDM) - ANSWER-The physician's thought process
Mid level provider (MLP) - ANSWER-Advanced Practice Provider
(APP) Nurse Practitioner (NP) or Physician Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant (MA) - ANSWER-Records medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers medications,
assists with procedures
Receptionist - ANSWER-Answers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - ANSWER-Documents the patient's visit on behalf of the physician
A scribe is an: - ANSWER-Unlicensed person performing documentation and other non-
clinical tasks under the direction of a healthcare provider.
, Scribes CAN... - ANSWER--Document the history, physical exam, results, procedures,
assessment, and plan
-Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
Scribes CANNOT... - ANSWER--Partake in any activity that may affect patient health or
outcome
-Touch Patients
-Handle Bodily fluids or specimens
-Sign or authenticate any chart or record
-Give verbal orders or submit electronic orders
New patients - ANSWER-No previous records, longer visit, detailed chart
Established patients - ANSWER-Previous records available, shorter visit, concise chart,
have been seen in the clinic within 3 years
Diagnostic Visit - ANSWER-New problem, chief complaint is a new symptoms, the goal
is to determine the cause of the problem and the appropriate treament
Health Management Visit - ANSWER-Check-up, chief complaint is a routine physical or
management of chronic problem(s), goal is preventative care and/or assessing progress
of ongoing medical problems.
Clinic Flow: Physician Evaluation - ANSWER-Review the patient's medical records.
A&P from the previous visit, labs and/or imaging results.
H&P includes HPI, ROS, PE.
Differential Dx (DDx) only for diagnostic visits. Possible Dx that may be causing the
symptoms.
Clinic Flow: Results - ANSWER-May result during visit, or in a few days
Clinic Flow: Assessment - ANSWER-The list of current diagnoses
Clinic Flow: Plan - ANSWER-Follow-up and treatment plan for each diagnosis
Clinic Flow: Check-out - ANSWER--Home vs. sent to the ED
-Patient education provided
-Patient will often stop at the front desk on the way out to schedule next appointment
Sections of a Chart (SOAP) - ANSWER-Subjective: HPI and ROS
Pa
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