Scribe america stuvia - Study guides, Class notes & Summaries

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...

last day of the month - ANSWERget paid on what day for hours worked 10th-24th? 16th - ANSWERget paid on what day for hours worked 25th-9th? Sunday - ANSWERthe work week starts on what day of the week? subjective - ANSWERfeeling (from patient) objective - ANSWERfact (from provider) pain - ANSWERpatient's feeling, subjective tenderness - ANSWERphysician's observation, objective benign - ANSWERnormal, nothing of conern acute - ANSWERof new onset, less than 3 months chro...

abscess - ANSWERcollection of pus underneath the skin acute - ANSWERnew, usually rapid onset, opposite of chronic afebrile - ANSWERwithout a fever (less than 100.4) anterior - ANSWERlocated towards the front of body appendicitis - ANSWERinfection of the appendix auscultation - ANSWERlistening with a stethoscope benign - ANSWERnormal, not of concern catheter - ANSWERtube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage op...

scribes can - ANSWERdocument the SOAP scribes cannot - ANSWERpartake 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 new patient - ANSWERno previous records; longer visit; detailed chart established patient - ANSWERprevious records available; shorter visit; concise chart diagnostic clinic visit - ANSWERnew problem; cc: new symptom; goa...

HTN CC - ANSWERSasymptomatic HLD CC - ANSWERSasymptomatic DM CC - ANSWERSpolyuria, polydipsia CAD CC - ANSWERSCP or pressure Asthma CC - ANSWERSSOB, wheezing How do you diagnose HTN? - ANSWERSCheck BP How do you diagnose HLD? - ANSWERSCheck bloodwork How do you diagnose DM? - ANSWERSFasting blood glucose, HA1C How do you diagnose HLD? - ANSWERSCheck blood work for LDL levels How do you diagnose CAD? - ANSWERSCardiac Catheterization by cardiologist How do you diagnos...

HTN CC - ANSWERSasymptomatic HLD CC - ANSWERSasymptomatic DM CC - ANSWERSpolyuria, polydipsia CAD CC - ANSWERSCP or pressure Asthma CC - ANSWERSSOB, wheezing How do you diagnose HTN? - ANSWERSCheck BP How do you diagnose HLD? - ANSWERSCheck bloodwork How do you diagnose DM? - ANSWERSFasting blood glucose, HA1C How do you diagnose HLD? - ANSWERSCheck blood work for LDL levels How do you diagnose CAD? - ANSWERSCardiac Catheterization by cardiologist How do you diagnos...

HTN CC - ANSWERSasymptomatic HLD CC - ANSWERSasymptomatic DM CC - ANSWERSpolyuria, polydipsia CAD CC - ANSWERSCP or pressure Asthma CC - ANSWERSSOB, wheezing How do you diagnose HTN? - ANSWERSCheck BP How do you diagnose HLD? - ANSWERSCheck bloodwork How do you diagnose DM? - ANSWERSFasting blood glucose, HA1C How do you diagnose HLD? - ANSWERSCheck blood work for LDL levels How do you diagnose CAD? - ANSWERSCardiac Catheterization by cardiologist How do you diagnos...

last day of the month - ANSWERget paid on what day for hours worked 10th-24th? 16th - ANSWERget paid on what day for hours worked 25th-9th? Sunday - ANSWERthe work week starts on what day of the week? subjective - ANSWERfeeling (from patient) objective - ANSWERfact (from provider) pain - ANSWERpatient's feeling, subjective tenderness - ANSWERphysician's observation, objective benign - ANSWERnormal, nothing of conern acute - ANSWERof new onset, less than 3 months chro...

scribes can - ANSWERdocument the SOAP scribes cannot - ANSWERpartake 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 new patient - ANSWERno previous records; longer visit; detailed chart established patient - ANSWERprevious records available; shorter visit; concise chart diagnostic clinic visit - ANSWERnew problem; cc: new symptom; goa...

abscess - ANSWERcollection of pus underneath the skin acute - ANSWERnew, usually rapid onset, opposite of chronic afebrile - ANSWERwithout a fever (less than 100.4) anterior - ANSWERlocated towards the front of body appendicitis - ANSWERinfection of the appendix auscultation - ANSWERlistening with a stethoscope benign - ANSWERnormal, not of concern catheter - ANSWERtube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage op...