Medical Scribe Bundled Exams with complete solution

In your own words, describe the significance of an HPI - The HPI is the story of the symptoms and events that led to the patient's ED visit. It includes the CC and the associated sx. How is the HPI different from the ROS? - The HPI focus is a story about the chief complaint and its associated sy...

CAD - coronary artery disease HTN MOI - hypertension mechanism of injury DM - diabetes mellitus MI - myocardial infarction CHF - congestive heart failure AFIB - atrial fibrillation PE - pulmonary embolism (d-dimer) DVT - deep venous thrombosis (d-dimer) BKA - below knee amputationPTX - p...

What is the chief complaint? - the reason the patient is coming in to be seen by the provider; ED and outpatient What is the history of present illness? - this section is used to expand and describe the chief complaint; subjective from patient and family what is an example of HPI? - mary wallace...

What are the 5 vital signs? - 1. Heart rate 2. Blood pressure 3. Respiratory rate 4. Temperature 5. Oxygen saturation The HPI and the ROS are what type of information? - The physical exam is what kind of information? - While evaluating a patient complaining of chest pain, your physician tel...

Subjective - Based on pt's feelings Objective - Factual info from provider HPI - History of Present Illness History of Present Illness -Story of pt's chief complaint ROS - Review of Systems Review of Systems - Head to toe checklist of pt's symptoms Intermittent - Comes and goes (0-100) Wax...

TRUE or FALSE: Accessing patient information electronically can be trace back to your user ID and computer and defines the documents and time spent accessing the records. - TRUE (Practice safe internet use; accessing patient information electronically or questionable websites can be traced back to...

cornea - transparent coat of eyeball that covers iris and pupil lets light into eye scelera - dense fibrous opaque outer coat enclosing the eyeball- except part covered by cornea conjunctiva - white of eyes icterus - yellowing of scelera due to bilirubin buildup often seen with juandice subcon...

HPI - history of present illness ROS - Review of Systems PE - Physical Examination A/P - acssessment and planning CC - Chief Complaint Chief Complaint - statement or reason for the patient encounter History of present illness - detailed description of development of the patients present diseas...

There are ____ systems in the human body - 11 In terms of charting in the ED, ____ is the information from the patient - subjective In terms of charting in the ED, ____ is the information from the provider and the data - objective The patient's story of why they are at the ED. What type of infor...

vital signs - a series of measures that give an overview of a patient's overall health; heart rate, respiratory rate, blood pressure, body temperature, oxygen saturation heart rate - the rate that your heart is pumping blood (beats per minute) (normal: 60-100 bpm) respiratory rate - rate of some...

SOAP - Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) Assessment-Diagnosis (determined by combining subjective/objective info) Plan-Disposition (Admission, Discharge, Transfer instructions) 7 Part...

anterior - toward the front posterior - toward the back superior - toward the head inferior - towards the feet medial - toward the midline lateral - away from the midline proximal - Nearer to the trunk of the body distal - Farther from the trunk of the body plantar - sole of foot dorsal - t...