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Class 1 Flashcards

(89 cards)

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1
Q

EHR

A

electronic health record

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2
Q

What is the role of the scribe?

A

to share the clinician’s burden of data gathering and chart documentation

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3
Q

What can scribes not do?

A

touch patients, write orders or prescriptions, give verbal orders, sign anything on behalf of provider, handle bodily fluids or specimens

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4
Q

Chief complaint

A

the main reason for the patient’s outpatient visit

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5
Q

EMR / EHR

A

electronic medical record / electronic health record

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6
Q

Subjective

A

feeling

oftentimes how a patient says they are feeling

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7
Q

Objective

A

factual findings from the provider

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8
Q

Pain

A

patient’s feeling of discomfort

subjective

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9
Q

Tenderness

A

Doctor’s finding of reproducible pain

objective

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10
Q

Acute

A

new onset, likely concerning

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11
Q

Chronic

A

Long-standing, not of direct concern

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12
Q

What constitutes a new patient?

A

A patient that has never been seen at the organization

A patient that was seen 3 years or more ago

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13
Q

If a patient goes to a different clinic within the same organization are they a new patient?

A

No, their information is available in the charts

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14
Q

Diagnostic exams

A

Address a new concern

The chief complaint is a new symptom

Goal is to determine the cause of the problem and treatment plan

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15
Q

Health management exams

A

Check-ups

The chief complaint is a routine physical or management of chronic problems

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

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16
Q

What is the order of the clinic flow?

A
  1. Check In and Chief Complaint
  2. History and Physical
  3. Orders and Results
  4. Assessment and plan
  5. Check Out
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17
Q

Who does the Check-In and Chief Complaint?

A

Nurse or MA

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18
Q

What are the 5 vital signs?

A 
HR: heart rate (bpm)
BP: blood pressure (mmHg)
RR: respiratory rate 
T: temperature 
SaO2: Oxygen saturation (%)
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19
Q

HPI

A

History of Present Illness

the story and context of the chief complaint

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20
Q

ROS

A

review of systems

a head-to-toe list of positive and negatives

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21
Q

PE

A

physical exam

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22
Q

DDx

A

list of possible diagnoses (Dx) that could be causing patient’s complaints

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23
Q

What type of visits do DDx occur?

A

only at diagnostic visits

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24
Q

What is the acronym for the structure of the medical chart?

A

SOAP

subjective, objective, assessment, plan

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25
Subjective parts of medical chart
History of Present Illness (HPI) Review of Systems (ROS) Past history (kinda)
26
What are the four parts of patient history?
medical, surgical, social and family
27
Objective parts of medical chart
Physical examination (PE) Orders and results
28
What goes in the assessment part of chart?
current diagnoses
29
What goes in the Plan part of chart?
treatment plan and follow-up
30
PMHx
past medical history
31
High blood pressure
hypertension (HTN)
32
High cholesterol
Hyperlipidemia (HLD)
33
Diabetes
Diabetes Mellitus (DM)
34
"I only take pills for my diabetes"
Non-insulin dependent diabetes mellitus | NIDDM
35
"I only take shots for my diabetes"
Insulin dependent diabetes mellitus IDDM
36
Heart disease
Coronary Artery Disease CAD
37
Heart attack
Myocardial Infarction MI
38
Heart failure
Congestive heart failure CHF
39
Irregular heartbeat
Arrhythmia
40
Emphysema or chronic bronchitis
Chronic Obstructive Pulmonary Disease COPD
41
Blood clot in lung
Pulmonary Embolism PE
42
Pneumonia or lung infection
Pneumonia PNA
43
Reflux
Gastroesophageal Reflux Disease GERD
44
Ulcers
Gastric/Peptic Ulcer Disease PUD
45
Irritable bowel
Irritable bowel syndrome IBS
46
Bladder infection
Urinary tract infection UTI
47
Kidney infection
Pyelonephritis
48
I'm on dialysis
Chronic Kidney Disease CKD
49
Enlarged prostate
Benign Prostatic Hypertrophy BPH
50
Stroke
Cerebrovascular Accident CVA
51
blood clot in brain
ischemic CVA
52
Brain bleed
Hemorrhagic CVA
53
Mini stroke
transient ischemic attack TIA
54
Blood clot in my leg
Deep vein thrombosis DVT
55
Bulge in my aorta
Aortic aneurysm
56
Bad blood flow in my legs
Peripheral vascular disease PVD
57
Cancer
Cancer or Carcinoma CA
58
Spread to my ...
With metastasis to the ...
59
Chemo
chemotherapy
60
Radiation
radiation therapy
61
"they cut it out"
Status-post surgical resection
62
Cancer is gone
In remission
63
When does scribe have to pay attention to home medications?
If they are part of the HPI / story the patient brought
64
True allergy to medicine
rash, itching, swelling, or difficulty breathing
65
Adverse reaction
reaction to medicine that does not constitute as a true reaction
66
PSHx
past surgical history
67
Tonsils removed
Tonsillectomy
68
-ectomy
suffix that means removal
69
Adenoids removed
Adenoidectomy
70
"Neck arteries cleaned"
Carotid endarterectomy
71
Leg amputated
above knee amputation (AKA) below knee amputation (BKA)
72
Joint repair
arthroplasty
73
Balloon in my heart
Balloon angioplasty
74
Stents in my heart
coronary stents
75
Heart bypass
coronary artery bypass graft CABG
76
breast removal
mastectomy
77
part of my lung removed
partial lobectomy
78
appendix removed
appendectomy
79
gallbladder removed
cholecystectomy
80
Part of my colon removed
partial colectomy
81
Spleen removed
splenectomy
82
kidney removed
nephrectomy
83
uterus removed
hysterectomy
84
ovary removed
oophorectomy
85
FHx
family history includes any medical condition present in the patient's blood relatives
86
What age indicates a higher genetic risk?
under 55 if relative developed a disease under 55, it is a higher chance of being a genetic disease
87
SHx
social history
88
What goes in the SHx?
alcohol use, tobacco use, drug use, occupation, living circumstances
89
How do you record tobacco use?
ppd packs per day

Scribe (6 decks)

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