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Study Guide for ScribeAmerica Final Best Rated Test Bank
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  • Course
  • ScribeAmerica
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  • ScribeAmerica

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 ...

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  • August 7, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • study guide for scribeamerica final best rated tes
  • study guide for scribeamerica final stuvia
  • subjective answer feeling patient objective

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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: Orders - ANSWER-Lab studies, imaging studies, procedures.

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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