SA OP Final (personally made)
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567 Terms
What is the role of a scribe (3)?
share the clinicians burden of data gathering and chart documentation
we are present during all data gathering including the patient conversation, physical exam, labs and imaging, and re-evaluations
also have to update the electronic health record for the provider, so they can concentrate on the patient
What can scribes do (5):
document the history, physical exam, results, procedures, and consults
access and document laboratory results and radiology findings
access display xrays for the physician to review
locate and obtain medical history, previous charts and past results
record physician interpretations of xrays and ECGs
what can scribes NOT do (5):
anything they are not trained to do, specifically DO NOT touch the patient unless you have been specifically trained 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 to do so
Your provider, Dr. 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
What are scribe perks (8):
learn about medicine (diseases, symptoms, diagnoses, and treatments, terminology, etc.)
learn how to document like a clinican
gain first hand experience in healthcare
build lasting relationships
opportunity for letters of recomendation
great resume builder
lots of options for career advancement
experience is fun and rewarding
what is the main reason for the pt’s OP visit
chief complaint
what does EMR/EHR stand for?
electronic medical record/electronic health record
what the patient is feeling is referred to as
subjective
the factual finding from the provider is referred to as
objective
the pt’s feeling of discomfort is
pain
doctors findings of reproducible pain is known as
tenderness
a new onset, likely concerning is referred to as
acute
long-standing, not of direct concern is referred to as
chronic
What are the two types of pts?
new and established
A patient that has never been seen at the clinic or was seen greater than 3 years ago, has no previous records is what
new patient
new patients require what
longer visit and a detailed chart
a patient that has been seen at the clinic (by any provider) within the last 3 years, has previous records available is what type of pt
established
established patients have normally
shorter visits with a concise chart
what are the two types of visits?
diagnostic and health management
diagnostic visits consist of a
new problem
what is the goal of a diagnostic visit
to determine the cause of the problem and appropriate treatment
what does a health management visit consist of?
check-up
a chief complaint with a new symptom is what type of visit
diagnostic
what type of visits have a chief complaint of routine physical or management of chronic problem(s)
health management
what is the goal of a health management visit?
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 pt
Rick made an appointment because he developed a rash a few days ago. What type of visit is this?
diagnostic visit
Karrie has an appointment for management of her diabetes. What type of visit is this?
health management visit
what is the overview of the clinical flow?
check in & chief complaint
history and physical
orders and results
assessment and plan
check out
when a pt arrives (typically by walk-in, but could also be by EMS) and then assigned a room what happens?
nurse or MA takes assessment
what is in the nurse or MA assessment?
chief complaint (CC)
diagnostic vs health management
vital signs
height
weight
smoking status
review of allergies and medications
CC stands for
chief complaint
what constitutes vital signs?
heart rate (bpm), blood pressure (mmHg), respiratory rate, temperature (C or F)
oxygen saturation (%)
HR stands for
heart rate (bpm)
BP stands for
blood pressure (mmHg)
what does RR stand for?
Respiratory Rate
what does T stand for
temperature (C or F)
what does SaO2 stand for
oxygen saturation (%)
before entering the room, what happens
provider will review the pt’s medical records including assessment and plan from the previous visit along with labs and/or imaging results
what constitutes history and physical ?
history of present illness (HPI), review of systems (ROS), past history, physical exam (PE), and DDx but this is only for diagnostic visits (list of possible Dx that could be causing the pts compaints).
what does H&P stand for
history and physical
HPI stands for
history of present illness
ROS stands for
review of systems
PE stands for
physical exam
Dx stands for
diagnosis
what is the only thing in the H&P that is not listed unless it is for a diagnostic visit?
DDx
Physician order can include what type of things:
laboratory studies, imaging studies, procedures, and results
what is in laboratory studies
blood work, urinalysis, microscopy, cultures
what is in imaging studies
EKG, Xray, CT, ultrasound
what is in procedural studies:
sutures, joint reduction, splints
results can be released when?
during the visit (rare) or in a few days
in the physicians assessment, what is involved
the list of current diagnoses and summary of the visit
what is involved in the physicans plan?
treatment plan
what is involved in the treatment plan:
instructions for lifestyle changes, medications, and follow-up
what is involved in 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
what types of visits will have differential diagnoses listed in the assessment?
diagnostic visits
DDx stands for
differential diagnoses
what is the correct order of the patient’s flow through the clinic?
check in, history, physical exam, orders/results, assessment/plan, check out
the medical chart is written using
SOAP
SOAP stands for
subjective complaints, objective evaluation, assessment, plan
the S in soap consists of
HPI, ROS
is past history in the SOAP
no
O in soap consists of
PE and orders/results
A in SOAP involves
assessment
P in SOAP involves
plan
what is the flow of the medical chart
HPI, ROS, past history, PE, orders and results, assessment, and plan
what is the story and context of the chief complaint
HPI
a head to toe list of positive and negatives is what
ROS
what consists of 4 parts: medical, surgical, social, and family
past history
what is the physicians objective findings listed in
PE
where is the current diagnoses written in?
assessment
where is the treatment plan and follow up written
plan
where do you write the pt complaint?
HPI or ROS
past diagnoses/surgeries is written in
past history
the physicians observations is written in
physical exam
the labs, imaging, and studies, are written in
results
the current diagnoses is written in
assessment
the treatment plan is written in
plan
what is subjective
the patient complaint, HPI/ROS
what is the objective evaluation?
physicians observations, labs, imaging, studies, PE and Exam
has a prior diagnoses of hyperlipidemia
medical history
lungs are clear to auscultation
PE
had gallbladder removed
surgical history
chest xray shows pneumonia
results
heart rate is 95 bpm
vital signs
i’ve had a cough for three days
HPI/ROS
what is layman’s term
what the patient will likely call the disease
what the scribe/provider will document is
medical term
if the patient says high blood pressure, the scribe writes
hypertension (HTN)
if the patient says high cholesterol, the scribe writes
hyperlipidemia (HLD)
if the patient says diabetes, the scribe writes
diabetes mellitus (DM)
if the patient says “i only take pills for my diabetes”, the scribe writes
non-insulin dependent diabetes mellitus (NIDDM)
if the patient says “I take shots (insulin) for my diabetes”, the scribe writes:
insulin dependent diabetes mellitus (IDDM)
if the patient says heart disease, the scribe writes
usually coronary artery disease (CAD)
if the patient says heart attack, the scribe writes
myocardial infarction (MI) and CAD
if the patient says heart failure, the scribe writes:
congestive heart failure (CHF)
if the patient says irregular heartbeat, the scribe writes
arrhythmia
if the patient says emphysema or chronic bronchitis, the scribe writes
chronic obstructive pulmonary disease (COPD)
if the patient says blood clot in lung, the scribe writes
pulmonary embolism (PE)
if the patient says pneumonia or lung infection, the scribe writes
pneumonia (PNA)