Outpatient Course One

Made by Scribe America as of 6/11/2026

What is a scribe?

Scribes share the provider's burden of data gathering & chart documentation (in an EHR). We are present during all data gathering including the patient conversation, physical exam, labs and imaging, and re-evaluations.

Can scribes touch patients?

No

Can scribes access and display X-rays for the provider to review?

Yes!

Can scribes give or pass on verbal orders?

No

Can scribes handle bodily fluids or specimens?

No

EHR/EMR

Electronic Health Record (EHR)

Electronic Medical Record (EMR)

This is the electronic charting system your hospital or clinic uses. Examples include Epic and Cerner.

Chief complaint

The main reason for the patient's outpatient visit

What is the difference between Subjective and Objective

Subjective information is based on a feeling. Typically comes from the patient (or other historian).

Objective information is factual information. Typically comes from provider or objective testing (labs, imaging, etc).

Pain vs Tenderness

Pain is a subjective term (comes from the patient)

Tenderness is an objective term (appreciated by the provider)

Acute

New onset, likely concerning

Opposite of chronic

Chronic

Long-standing, not of direct concern

Opposite of acute

An established patient is one that has been seen at the clinic (by any provider) within the last ______ years.

three

New patients do not have any previous records. How might this alter the length of the visit?

New patients typically require LONGER visits, and more detailed charts.

Diagnostic vistis

Health Management Visits

clinic flow

check in and chief complaint > nurse assessment > H&P > orders and results > assessment and plan > check out

what is the term that describes the symptom or problem that brought the patient into the clinic today?

chief complaint (CC)

What type of visits will have differential diagnoses listed in the Assessment?

diagnostic visits

SOAP stands for

Subjective, Objective, Assessment, and Plan

patient complaints belong in what section(s) of the chart?

HPI and ROS

previous diagnoses and surgeries belong in what section(s) of the chart?

Past history

The provider's observations belong in what section(s) of the chart?

Physical Exam

What does PMHx stand for?

past medical history

If the patient states they have, "high blood pressure," what will you document in the PMHx?

hypertension (HTN)

If the patient states they have, "high cholesterol," what will you document in the PMHx?

hyperlipidemia (HLD)

If the patient states," "I only take pills for my diabetes" what will you document in the PMHx?

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

If the patient states they have, "heart disease," what will you document in the PMHx?

coronary artery disease or CAD

If the patient states they have had a, "heart attack," what will you document in the PMHx?

myocardial infarction or MI

If the patient states they have, "heart failure," what will you document in the PMHx?

congestive heart failure or CHF

If the patient states they have, "emphysema," what will you document in the PMHx?

chronic obstructive pulmonary disease or COPD

What is the medical term for a blood clot in the lung?

pulmonary embolism (PE)

What is the medical term for reflux or "acid reflux"

gastroesophageal reflux disease (GERD)

What is the medical term for a bladder infection

urinary tract infection (UTI)

What is the medical term for a kidney infection

pyelonephritis

What is the medical term for a stroke

cerebrovascular accident (CVA)

which type of stroke can be described as a "blood clot in the brain?"

ischemic cerebrovascular accident

which type of stroke can be described as a "brain bleed?"

hemorrhagic cerebrovascular accident

What is the medical term for a mini stroke

transient ischemic attack

blood clot in my leg

deep vein thrombosis

bad blood flow in my legs

peripheral vascular disease

What does PSHx stand for?

past surgical history

tonsils removed

tonsillectomy

adenoids removed

adenoidectomy

"neck arteries cleaned"

carotid endarterectomy

"balloon in my heart"

angioplasty

"stents in my heart"

coronary stents

heart bypass

coronary artery bypass graft

breast removal

mastectomy

Part of my lung removed

partial lobectomy

appendix removed

appendectomy

gallbladder removed

cholecystectomy

part of my colon removed

partial colectomy

spleen removed

splenectomy

part of my colon removed

partial colectomy

kidney removed

nephrectomy

uterus removed

hysterectomy

ovary removed

oophorectomy

FHx stands for

family history

Examples of social history

alcohol use, tobacco use, substance use, occupation, living circumstances