ScribeAmerica

Chief Complaint Correct Answer: the main reason for the pt's ED visit pain vs tenderness Correct Answer: pt's feelings (subjective) vs physician's assessment (objective) distress Correct Answer: the doctor's judgement of discomfort baseline Correct Answer: an individual's normal state of being What CAN scribes do? Correct Answer: -Document Hx, PE, results, procedures, and physician consults -Access and document lab results and radiology findings -Locate and obtains PMHx, ...

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

associated dz for epigastric region Correct Answer: GERD, Mi 5 vital signs Correct Answer: HR BP RR temp O2 Sat what is the difference between HPI and ROS Correct Answer: ROS-- head to toe checklist of sx (includes chirf complaint, associated sx, and other complaints patient may have HPI--focuses on the details related to the chief complaint what does dispo mean Correct Answer: the patients destination after they leave the ED what subcategories are included within the past ...

What is HITECH? What does it do? Correct Answer: Health Information Technology for Economic and Clinical Health Act 2009; as an addition to HIPAA to address the privacy and security issues related to electronic transmission of health information. Information cannot be transferred electronically, copied, stored on external devices or sent without special security known as encryption What are the 8 Main HIPAA Rules? Correct Answer: 1. Only Access PHI to do your job 2. Never share your...

Which of the following would belong in a psychiatric exam? Correct Answer: Affect Certain words or phrases act as "red flags" to grab your provider's attention to let them know that a patient may require timely and comprehensive medical action. Which of the following words or phrases are NOT considered "red flags"? Correct Answer: nocturia in a 65 year old male What does LBBB stand for? Correct Answer: Left Bundle Branch Block What does URI stand for? Correct Answer: Upper Resp...

What are the 5 vital signs? Correct Answer: Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation The HPI and ROS are what type of information? Correct Answer: subjective The Physical Exam is what type of information? Correct Answer: objective What is the difference between the HPI and ROS? Correct Answer: HPI focuses on details related to the pt's chief complaint. ROS is a head-to-toe checklist of symptoms, including the chief complaint, associated sx, and ...

* What medical term describes the surgical removal of the gallbladder? Correct Answer: cholecystectomy What does "PHI" stand for? Expand the abbreviation. Correct 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. Correct Answer: False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? Correct...

What are the 3 types of dispositions? Correct Answer: Discharge, Admit, Transfer What does HPI stand for? Correct Answer: history of present illness What does ROS stand for? Correct Answer: review of systems The HPI and ROS are considered what type of information? Correct Answer: subjective The physical exam is what type of information? Correct Answer: objective If a physician told you a patient's abdomen was non tender, where would you document this? Correct Answer: PE ...

Abrasion Correct Answer: Scrape of the skin due to something abrasive. Acute Correct Answer: New, usually of rapid onset and of concern, opposite of chronic. Anterior Correct Answer: Located towards the front of the body. Benign Correct Answer: Normal, of no danger to health. Bradycardia Correct Answer: Slow heart-rate (less than 60bpm) Cardiomegaly Correct Answer: Enlarged Heart Cholecystitis Correct Answer: Inflammation of the cholecyst (gallbladder) Chronic Correct...

What is the standard template for charting? Correct Answer: HPI, ROS, Past History, PE, ED Course, Disposition What are some general PMHx? Correct Answer: Hypertension (HTN), Hyperlipidemia, Cancer, Diabetes Mellitus (IDDM, NIDDM) What are some cardiac PMHx? Correct Answer: Myocardial Infarction, Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation What are some pulmonary PMHx? Correct Answer: Pulmonary Embolism, Pneumonia, Chronic Obstructive Pulmonary Disease, As...