Scribeamerica op stuvia Study guides, Class notes & Summaries

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 ...

New Patient - ANSWERNo previous records, longer visit, detailed chart established patient - ANSWERPrevious records available from last 3 years, shorter visit, concise chart Diagnostic visit - ANSWERNew problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment health management - ANSWERcheck up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems Cli...

pain vs tenderness - ANSWERpatient's feeling vs physician's assessment acute vs chronic - ANSWERnew onset vs long standing Meaningful Use (MU) - ANSWERa set of government mandated criteria that must be obtained for every patient Medical decision making - ANSWERthe physician's thought process Mid-level providers: - ANSWERNurse Practitioner (LNP) or Physician's Assistant (PA) that works under the supervision of a physician to diagnose and treat patients Nurse or Medical Assistan...

* What medical term describes the surgical removal of the gallbladder? - ANSWERcholecystectomy What does "PHI" stand for? Expand the abbreviation. - ANSWERProtected 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. - ANSWERFalse ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - ANSWERcraniotomy A patient's...

New Patient - ANSWERNo previous records, longer visit, detailed chart established patient - ANSWERPrevious records available from last 3 years, shorter visit, concise chart Diagnostic visit - ANSWERNew problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment health management - ANSWERcheck up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems Cli...

pain vs tenderness - ANSWERpatient's feeling vs physician's assessment acute vs chronic - ANSWERnew onset vs long standing Meaningful Use (MU) - ANSWERa set of government mandated criteria that must be obtained for every patient Medical decision making - ANSWERthe physician's thought process Mid-level providers: - ANSWERNurse Practitioner (LNP) or Physician's Assistant (PA) that works under the supervision of a physician to diagnose and treat patients Nurse or Medical Assistan...

* What medical term describes the surgical removal of the gallbladder? - ANSWERcholecystectomy What does "PHI" stand for? Expand the abbreviation. - ANSWERProtected 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. - ANSWERFalse ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - ANSWERcraniotomy A patient's...