Scribe america stuvia Study guides, Class notes & Summaries

* What medical term describes the surgical removal of the gallbladder? - Answer cholecystectomy What does "PHI" stand for? Expand the abbreviation. - Answer Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - Answer False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Answer craniotomy A patien...

What does "PHI" stand for? Expand the abbreviation - Answer protected health information What medical term describes the surgical removal of the gallbladder? - Answer cholecystectomy T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case - Answer False A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP ...

Subjective - Answer Feeling, pain, CC, HPI, ROS Objective - Answer Fact, tenderness, PE, results pain - Answer pt's feeling tenderness - Answer physician assessment benign - Answer normal, nothing of concern acute - Answer new onset chronic - Answer long-standing; more than 3 months auscultation - Answer listening with stethoscope palpation - Answer pressing on an area (physician) inpatient - Answer admitted to hospital overnight outpatient - Answer seen and sent h...

subjective vs objective - Answer feeling vs fact pain vs tenderness - Answer patients feeling vs physicians assessment benign - Answer normal, nothing of concern acute vs chronic - Answer new onset vs long standing baseline - Answer an individuals normal state of being ausculation - Answer listening to sound with a stethoscope palpation - Answer act of pressing on an area (by the physician) inpatient - Answer admitted to the hospital overnight outpatient - Answer seen and...

Subjective vs objective: - Answer Feeling (patient) vs fact (provider) Pain vs Tenderness: - Answer patient's feeling (subjective) vs physician's observation (objective) Benign: - Answer Normal, nothing of concern Acute vs chronic: - Answer new onset vs long standing [does not indicate severity] Baseline: - Answer individual's normal state of being Auscultation: - Answer listening with a stethoscope Palpation: - Answer the act of pressing on an area (by the physician) Inp...

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 ...

CAD - Answer Coronary Artery Disease HTN - Answer Hypertension DVT - Answer Deep Vein Thrombosis DM - Answer Diabetes Mellitus (Type I or Type II) CHF - Answer Congestive Heart Failure GERD - Answer Gastroesophogeal Reflux Disease COPD - Answer Chronic Obstructive Pulmonary Disease MI - Answer Myocardial Infarction URI - Answer Upper Respiratory Infection UTI - Answer Urinary Tract Infection CA - Answer Cancer CVA - Answer Cerebrovascular Accident / Costovertebra...

CBC - Answer Complete Bood Count (WBC, H&H, RBC, Plt) BMP - Answer Basic Metabolic Panel (several electrolights, gluc, and creatinine) CMP - Answer Complete Metabolic Panel (BMP plus LFT's) LFT - Answer Liver Function Test Micro UA - Answer quantitative urinalysis (not bedside) CEP - Answer Cardiac Enzyme Panel (Trop, CK, CK-MB, CK-RI, Myo) CBC with Diff - Answer A CBC with additional tests for infections (bands, segs, lymphs, monos, eos) Creatinine - Answer High levels ind...

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 v...

Aneurysm - ANSWER-Localized ballooning of a vessel due to a weakened vessel wall Arrhythmia - ANSWER-Irregular heartbeat Artery - ANSWER-Blood vessel carrying blood away from the heart, muscular, contractile Bradycardia - ANSWER-Slow heart rate (HR<60) Cardiomegaly - ANSWER-Enlarged heart Coronary artery - ANSWER-Artery that supplies the heart with blood Dorsalis pedis pulse - ANSWER-Pulse that is palpable on the dorsum (top) of the foot Murmur - ANSWER-Abnormal heart sou...