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ScribeAmerica - Introductory Training Packet Questions and Answers (GRADED A)
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Abrasion - ANSWER-Scrape of the skin due to something abrasive. Acute - ANSWER-New, usually of rapid onset and of concern, opposite of chronic. Anterior - ANSWER-Located towards the front of the body. Benign - ANSWER-Normal, of no danger to health. Bradycardia - ANSWER-Slow heart-rate (...

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Document information

  • August 7, 2024
  • 11
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

Subjects

  • scribeamerica introductory training stuvia
  • scribeamerica introductory training packet quest
  • abrasion answer scrape of the skin due to someth

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ScribeAmerica OP Final Exam flashcards
questions & answers( Verified 100%)


pain vs tenderness - ANSWER-patient's feeling vs physician's assessment

acute vs chronic - ANSWER-new onset vs long standing

Meaningful Use (MU) - ANSWER-a set of government mandated criteria that must be
obtained for every patient

Medical decision making - ANSWER-the physician's thought process

Mid-level providers: - ANSWER-Nurse Practitioner (LNP) or Physician's Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients

Nurse or Medical Assistant - ANSWER-records medical histories and symptoms,
monitors the patient, completes meaning 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

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

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

New patients - ANSWER--no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new

, Established patients - ANSWER--previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years

Diagnostic visit - ANSWER--new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary

Health Maintenance visit - ANSWER--check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems

allergy - ANSWER-a medication that causes a rash, itching, swelling, or difficulty
breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy

Hypertension (HTN) - ANSWER-high blood pressure

Hyperlipidemia (HLD) - ANSWER-high cholesterol

Normal heart rate - ANSWER-60-100 bpm

Pulmonary Embolism (PE) - ANSWER-blood clot in lung

Gravida/Para/Abortion - ANSWER-G - the total number of times the patient has been
pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions

Cerebrovascular Accident (CVA) - ANSWER-stroke

Transient Ischemic Attack (TIA) - ANSWER-mini-stroke

Tonsillectomy - ANSWER-tonsils removed

Adenoidectomy - ANSWER-adenoids removed

Coronary Artery Bypass Graft - ANSWER-heart bypass (PMHx CAD)

Angioplasty - ANSWER-balloon

Automatic Implanted Cardiac-Defribrillator (AICD) - ANSWER-defibrillator

Mastectomy - ANSWER-breast removal

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