Outpatient 1: Patient Health History and Terminology

Role of the Scribe

Gather data and chart documentation.

Present during all data gathering including the patient conversation, physical exam, labs and imaging, and re-evaluations.

Job of updating the Electronic Health Record (EHR) for the provider.

Scribes Can:

• Document the history, physical exam, results, procedures, and consults.

• Access and document laboratory results and radiology findings.

• Access and display x-rays for the physician to review.

• Locate and obtain medical history, previous charts and past results.

• Record physician interpretations of x-rays and ECGs.

Scribes Cannot:

• Do anything they are not trained to do. Do not touch patients unless trained on how to do so.

• Write orders or prescriptions .

• Give verbal orders.

• Sign or authenticate any chart or record (on behalf of the provider).

• Handle bodily fluids or specimens unless trained on how to do so.

Schroeder is tied up in a procedure, so he asks you to tell the nurse to draw up 4 mg of Morphine for the patient. Is this within the scope of a scribe?

No

Scribe Perks

• Learn about medicine (diseases, symptoms, diagnoses and treatments, terminology, etc.)

• Learn how to document like a clinician

• Gain firsthand experience in healthcare

• Build lasting relationships

• Opportunity for letters of recommendation

• Great Resume builder

• Lots of options for career advancement

Chief Complaint

The main reason for the patient’s outpatient visit.

EMR/EHR

Electronic medical record / electronic health record

Subjective

Feeling

How the patient is feeling (self).

Objective

Factual finding from the provider.

Pain

Patient’s feeling of discomfort. (subjective)

Tenderness

Doctor’s finding of reproducible pain. (objective)

Acute

New onset, likely concerning. (# < 3 months)

Chronic

Long-standing, not of direct concern.

Types of Patients: New

A patient that has never been seen at the clinic or was seen greater than 3 years ago.

No previous record

Longer visit

Detailed chart

Types of Patients: Established

A patient that has been seen at the clinic (by any provider) within the last 3 years.

Previous records available

Shorter visit

Concise chart

Types of Visits: Diagnostic

New problem

Chief complaint: new symptom

Goal is to determine the cause of the problem and appropriate treatment.

Types of Visits: Health Management

Check-up

Chief Complaint: Routine physical or management of chronic problems.

Goal is preventative care and/or assessing progress of ongoing medical problems.

Meera has been seen at your clinic, by Dr. Polik every 6 months for the past 2 years. She is here today for a routine appointment but is seeing Dr. Polik’s Nurse Practitioner. Is Meera considered a new or established patient today?

Established

Rick made an appointment because he developed a rash a few days ago: type of visit?

Diagnostic Visit

Karrie has an appointment for management of her diabetes: type of visit?

Health Management Visit

Clinic Flow Overview

• Check in & Chief Complaint

• History and Physical

• Orders and Results

• Assessment and Plan

• Check out

Check In and Chief Complaint

Patient arrives and then assigned a room.

Nurse or MA Assessment:

Chief Complaint (CC)

Diagnostic Vs. Health Management

Vital Signs

• HR: Heart Rate (bpm)

• BP: Blood pressure (mmHg)

• RR: Respiratory Rate

• T: Temperature (⁰C or ⁰F)

• Sa02: Oxygen Saturations (%)

Height, weight, smoking status, review allergies and medications.

History and Physical

Before entering the room

Provider will review the patient’s medical records:

• Assessment and plan from previous visits.

• Labs and/or imaging results.

Physician: History and Physical (H&P)

History of Present Illness (HPI)

Review of Systems (ROS)

Physical Exam (PE)

DDx - Only for diagnostic visits (List of possible Dx that could be causing patient’s complaints.)

Orders and Results

Physician: Orders

• Laboratory Studies: Blood work, urinalysis, microscopy, cultures.

• Imaging studies: EKG, X-Ray, CT, Ultrasound.

• Procedures: Sutures, Joint Reduction, Splints

Results:

May result during visit (rare) or in a few days.

Assessment and Plan

Physician: Assessment

The list of current diagnoses.

Summary of the visit

Physician: Plan

Treatment Plan:

• Instructions for lifestyle changes.

• Medications

• Follow-up

Check Out

• Home vs. sent to the ED

• Patient education provided

• Patient will often stop at the front desk on the way out to schedule next appointment.

The Medical Chart (KNOW THIS)

SOAP

S (Subjective Complaints)

• History of present illness (HPI): The story and context of the chief complaint.

• Review of systems (ROS): A head-to-toe list of positive and negatives.

O (Objective Evaluation)

• Physical Examination (PE): The physician’s objective findings.

• Order and Results

A (Assessment)

• Assessment: Current diagnoses.

P (Plan)

• Plan: Treatment plan and follow up.

The Medical Chart - Where to document: Patient Complaint

HPI or ROS (Subjective complaints)

The Medical Chart - Where to document: Past diagnoses/surgeries

Past history

The Medical Chart - Where to document: Physician’s observations

Physical exam (objective evauluation)

The Medical Chart - Where to document: Labs, Imaging Studies

Results (Objective evaluation)

The Medical Chart - Where to document: Current Diagnoses

Assessment

The Medical Chart - Where to document: Treatment Plan

Plan

Has a prior diagnosis of hyperlipidemia

Medical history

Lungs are clear to auscitation

Which choice would happen during a Physical Exam

What Type of History would be: Had gallbladder removed

Surgical history

Chest Xray shows pneumonia

Results (Example)

Heart rate is 95bpm

Vital signs

I’ve had a cough for three days

HPI/ROS

Layman’s term

What the patient will likely call the disease.

Medical Term

What the scribe/provider will document

The abbreviation

The shortened version of the disease.

PMHx

Past medical history

High Blood Pressure

Hypertension (HTN)

Hypertension Abbreviation

HTN

High Cholesterol

Hyperlipidemia (HDL)

Hyperlipidemia abbreviation

HLD

Diabetes

Diabetes Mellitus (DM)

Diabetes Mellitus Abbreviated

DM

“I only take pills for my diabetes”

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Non-Insulin Dependent Diabetes Mellitus abbreviated

NIDDM

“I take shots (insulin) for my diabetes”

Insulin Dependent Diabetes Mellitus (IDDM)

Insulin Dependent Diabetes Mellitus abbreviated

IDDM

Heart Disease

Usually Coronary Artery Disease (CAD)

Coronary Artery Disease Abbreviated

CAD

Heart Attack

Myocardial Infarction (MI) and CAD

Myocardial Infarction Abbreviated

MI

Heart Failure

Congestive Heart Failure (CHF)

Congestive Heart Failure (Abbreviated)

CHF

Irregular Heartbeat

Arrhythmia

Emphysema or Chronic Bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease Abbreviation

COPD

Blood clot in lung

Pulmonary Embolism (PE)

Pulmonary Embolism Abbreviated

PE

Pneumonia or lung infection

Pneumonia (PNA)

Pneumonia Abbreviated

PNA

Reflux

Gastroesophageal Reflux Disease (GERD)

GERD

Gastroesophageal Reflux Disease

Ulcers (Disease + Abbreviation)

Gastric Ulcer or Peptic Ulcer Disease (PUD)

PUD (What does it stand for)

Gastric Ulcer or Peptic Ulcer Disease

Irritable Bowel

Irritable Bowel Syndrome (IBS)

IBS

Irritable Bowel Syndrome

Bladder Infection

Urinary Tract Infection (UTI)

UTI

Urinary Tract Infection

Kidney Infection

Pyelonephritis

“I’m on dialysis”

Chronic Kidney Disease (CKD) on dialysis

CKD

Chronic Kidney Disease

Enlarged Prostate

Benign Prostatic Hyperplasia (BPH)

BPH

Benign Prostatic Hyperplasia

Stroke

Cerebrovascular Accident (CVA)

CVA

Cerebrovascular Accident (Abbreviation)

“Blood clot in brain”

Ischemia CVA

Brain Bleed

Hemorrhagic CVA

“Mini stroke”

Transient Ischemic Attack (TIA)

TIA

Transient Ischemia Attack

Blood clot in my leg

Deep vein thrombosis (DVT)

DVT

Deep vein thrombosis (Abbreviation)

“Bulge in my aorta”

Aortic Aneurysm

“Bad blood flow in my legs”

Peripheral Vascular Disease (PVD)

PVD

Peripheral Vascular Disease (Abbreviation)

The patient reports a history of acid reflux, high blood pressure, and a small brain bleed that did not require surgery. Which of the following should you include in the PMHx?

GERD

HTN

Hemorrhagic CVA

Cancer (Medical Name)

Cancer or Carcinoma (CA)

CA

Cancer or Carcinoma

Spread to my

With metastasis to the

Chemo

Chemotherapy

Radiation

Radiation Therapy

They cut it out

Status-post surgical resection

Status-Post (S/P)

After

Afterwards

It’s gone

In remission

True Allergy Symptoms

Rash

Itching

Swelling

Difficulty Breathing