Scribeamerica stuvia - Study guides, Class notes & Summaries

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...

Do any patient complaints belong in the physical exam? - ANSWER-NO If a patient states that their abdomen is very painful, does that mean it will be tender upon exam? - ANSWER-No. subjective info vs objective Which of these two physical exam findings can a physician appreciate without auscultating the Pt's lungs? a) No respiratory distress b) No Rales? - ANSWER-No respiratory distress What does PERRL stand for? - ANSWER-Pupils equal Round and reactive to light What does AT/NC stand ...

A&O - ANSWER-Alert and oriented A fib - ANSWER-Atrial fibrillation ABC - ANSWER-Airway, breathing, circulation ABG - ANSWER-Arterial blood pressure abnl - ANSWER-abnormal ACLS - ANSWER-Advanced cardiac life support ADH - ANSWER-Antidiuretic hormone ADLs - ANSWER-Activities of daily living AED - ANSWER-Automated external defibrillator AICD - ANSWER-Automated implantable cardioverter-defibrillator AIDS - ANSWER-Acquired immune deficiency syndrome ALS - ANSWER-Advan...

AAA - ANSWER-Abdominal Aortic Aneurysm A Fib - ANSWER-Atrial Fibrillation Abd - ANSWER-Abdomen, Abdominal Abx - ANSWER-Antibiotics AMA - ANSWER-Against Medical Advice AMS - ANSWER-Altered Mental Status ASA - ANSWER-Acetylsalicylic Acid (Aspirin) BID - ANSWER-Twice Daily Bilat LE - ANSWER-Bilateral Lower Extremities BM - ANSWER-Bowel Movement BP - ANSWER-Blood Pressure CA - ANSWER-Cancer, Carcinoma CABG - ANSWER-Coronary Artery Bypass Graft, "open heart surger...

New Patient - ANSWER-No previous records, longer visit, detailed chart established patient - ANSWER-Previous records available from last 3 years, shorter visit, concise chart Diagnostic visit - ANSWER-New problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment health management - ANSWER-check up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems ...

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 (less than 60bpm) Cardiomegaly - ANSWER-Enlarged Heart Cholecystitis - ANSWER-Inflammation of the cholecyst (gallbladder) Chronic - ANSWER-Long-standing, constant. Opposite of acute. COPD (C...

SOAP - ANSWER-subjective, objective, assessment, plan Examples of subjective data - ANSWER-HPI, ROS, PHx (medical, surgical, social, family Examples of objective data - ANSWER-Physical exams, orders and results Chief Complaint - ANSWER-The main reason for the patient's visit EMR/EHR - ANSWER-Electronic Medical Record/Electronic Health Record Subjective - ANSWER-Feeling Objective - ANSWER-Factual information from provider Pain - ANSWER-Feeling of discomfort Tenderness - A...

Different components of the SOAP note and what belongs in each section - ANSWER-Subjective includes - Chief Complaint (CC) - History of Present Illness (HPI) - Review of Systems (ROS) In between subjective and objective is the Past history (PMHx, PSHx, SHx, FHx) Objective include - Vital Signs (HR, RR, BP, T, O2Sat) - Physical Examination (PE) - Orders and results Assessment includes - Diagnosis - Description of progress since last visit Plan includes - Treatment and follow-up Cl...

What will the scribe document for the outpatient visit? - ANSWER-Important notes for past medical records History and Physical Laboratory and radiology results Physician Interpretation of XRs and EKGs Assessment and Plan Who is the first person to speak with the patient after he/she is placed in the room? - ANSWER-Nurse or MA What are the meaningful use requirements the nurse or MA will obtain? - ANSWER-Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status ...

What does ROS stand for? - ANSWER-Review of Systems The HPI and ROS are considered what type of information? - ANSWER-Subjective The physical exam (PE) is what type of information? - ANSWER-Objective If a physician told you a patient's abdomen was nontender or the patient's skin was pale, where would you document these pieces of information? - ANSWER-Physcal Exam (PE) What section focuses directly on the chief complaint? - ANSWER-History of Present Illness (HPI) What are the fiv...