Scribe America Outpatient Lesson 1 Exam With Complete Solution

1.1 What is the role of each person in the clinic and the scope of scribe? Mid-Level? Nurse/MA? Receptionist? Scribe? - Answer 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? - Answer 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? - Answer check-in, physician eval, orders & results, assessment and plan, check-out 1.4 How are patient visits documented? - Answer using S.O.A.P 1.5 How do scribes document past medical history? - Answer in Past History- PMedicalHx 1.6 How do scribes document past surgical history? - Answer in Past History - PSurgical Hx 1.7 How do scribes document family history? - Answer in Past History - FamilyMHx 1.8 How do scribes document social history? - Answer in Past History - SocialMHx 1.0 Subjective - Answer feeling (CC, HPI, ROS) 1.0 Objective - Answer fact (PE) 1.0 Benign - Answer normal, nothing of concern 1.0 Acute - Answer new onset 1.0 Chronic - Answer long standing 1.0 Baseline - Answer an individuals normal state of being 1.0 Auscultation - Answer listening with a stethoscope 1.0 Palpation - Answer act of pressing on an area (by the physician) 1.0 Inpatient - Answer admitted to the hospital overnight 1.0 Chief Complaint - Answer main reason for the patients visit 1.0 Meaningful Use - Answer set of government mandated criteria that must be obtained for every patient (vitals) 1.0 Medical Decision Making - Answer physicians thought process 1.1 What can scribes do? - Answer a. document the history, patient exam, results, procedures, assessment and plan b. access and document laboratory results and radiology findings c. locate and obtain PMHx, previous charts, past results, and recent studies d. record physicians interpretations of x-rays and EKG's