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Course 1: Introduction Flashcards

1. Roles in the clinic and scope of scribes 2. New vs. established patients? Two types of clinic visits? 3. How does a patient move through an outpatient clinic visit? 4. Document patient visits 5. Document PMHx 6. Document past surgical history 7. Document family history 8. Document social history (145 cards)

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1
Q

subjective vs. objective

A

subj: feeling (patient) vs. obj: fact (provider)

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2
Q

pain vs. tenderness

A

p: patient’s feeling (subjective) vs. t:physician’s observation (objective)

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3
Q

benign

A

not of concern; normal

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4
Q

acute vs chronic

A

acu: new onset vs. chr: long standing

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5
Q

baseline

A

an individual’s normal state of being

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6
Q

auscultation

A

listening to sounds arising within organs (such as the lungs) with a stethoscope

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7
Q

palpation

A

the act of pressing on an area (by the physician)

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8
Q

inpatient

A

admitted to the hospital overnight

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9
Q

outpatient (op)

A

seen and sent home the same day

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10
Q

chief complaint (CC)

A

the main reason for the patient’s visit

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11
Q

mid-level provider (MLP)

A

Advanced Practice Provider (APP), Nurse Practitioner (NP), or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients

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12
Q

nurse or medical assistant (MA)

A

records medical histories and symptoms, monitors the patient, completes meaningful use requirements, administers medications, assists with procedures

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13
Q

receptionist

A

answers phone calls, schedules appointments, answers patient questions, provides patient with summary of visit and written instructions from provider at check-out, and organizes the patient’s paperwork

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14
Q

scribe

A

documents the patient’s visit on behalf of the physician

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15
Q

The Scribe Scope: a scribe is an unlicensed person performing documentation and other non-clinical tasks under the direction of a healthcare provider. Scribes CANNOT ___ (pg. 113)

A

scribes CANNOT: partake in any activity that may affect patient health or outcome; touch patients; handle bodily fluids or specimens; sign or authenticate any chart or record; give verbal orders or submit electronic orders

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16
Q

new patient

A

no previous record; longer visit; detailed chart
*note: if it has been more than 3 years since the patient has been seen in this clinic, they will be considered new, regardless of being seen prior to their 3 year absence

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17
Q

established patient

A

previous records available; shorter visit; concise chart

*note: to be considered established, the patient must have been seen in this clinic within 3 years

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18
Q

diagnostic clinic visit

A

new problem; chief complaint = new symptom; goal is to determine the cause of the problem and appropriate treatment

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19
Q

health management clinic visit

A

check-up; chief complaint = routine physical or management or chronic problem(s); goal is preventative care and/or assessing progress of ongoing medical problems

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20
Q

Clinic Flow: how does a patient move through an OP clinic visit? (pg. 120)

A

check in–> physician evaluation–> orders and results–> assessment and plan–> check-out

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21
Q

Clinic Flow: check-in

A
  1. patient walks into clinic (diagnostic vs. health management)
  2. room placement
  3. Nurse/MA obtain quality measures (CC, height, weight, BMI, smoking status, vitals signs = HR, BP, T, RR, SpO2)
  4. Nurse/MA assessment (confirm CC, review allergies/medications, brief past medical history)
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22
Q

Clinic Flow: physical evaluation

A
  1. review patient’s past medical records (assessment and plan from the previous visit, labs and/or imaging results)
  2. history and physical (H&P) = HPI (history of present illness), ROS (review of systems), PE (physical exam)
  3. differential Dx (DDx) only for diagnostic visit = possible Dx that may be causing the symptoms
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23
Q

Clinic Flow: orders and results

A
  1. orders (laboratory studies, imaging studies, procedures)

2. results (may result during visit -rare- or in a few days)

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24
Q

Clinic Flow: assessment and plan

A
  1. assessment (the list of current diagnoses)
  2. plan (follow-up with specialist if necessary, instructions for lifestyle and preventative care, follow-up for next routine appointment)
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25
Clinic Flow: check-out
1. 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
26
How are patients visits documented? (pg. 128)
in a S.O.A.P. chart *note: for Health Management Visits, you will have a prior note to use as reference; the A.&P. of the prior visit are your guideline for today's visit - the assessment will give you a summary of history and their chief complaint, as well as findings and the plan from the last visit
27
S.O.A.P. => subjective
subjective complaints - patient complaint: HPI (story and context of the chief complaint) or ROS (checklist of pertinent positives and negatives) - past diagnosis or surgery: past history (PMSHx, SHx, FHx -->past diseases/surgeries, EtOH/tobacco, FHx)
28
S.O.A.P. => objective
objective evaluation - physician's observation: physical exam (provider's objective findings) - study: results - orders
29
S.O.A.P. => assessment
current diagnosis
30
S.O.A.P. => plan
treatment and follow-up
31
General PMHx: patient says, High blood pressure
scribe writes - hypertension (HTN)
32
General PMHx: patient says, High cholesterol
scribe writes - hyperlipidemia (HLD)
33
General PMHx: patient says, Thyroid problem
scribe writes - usually hypothyroidism (underactive thyroid), sometimes hyperthyroidism (overactive thyroid)
34
General PMHx: patient says, "I only take pills for my diabetes"
scribe writes - non-insulin dependent diabetes mellitus (NIDDM)
35
General PMHx: patient says, Diabetes
scribe writes, diabetes mellitus (DM)
36
General PMHx: patient says, "I take shots (insulin) for my diabetes"
scribe writes, insulin dependent diabetes mellitus (IDDM)
37
Cardiac PMHx: pt says, heart disease
scribe writes, usually coronary artery disease (CAD)
38
Cardiac PMHx: pt says, heart attack
scribe writes, myocardial infarction (MI) and CAD
39
Cardiac PMHx: pt says, heart failure
scribe writes, congestive heart failure (CHF)
40
Cardiac PMHx: pt says, irregular heartbeat *note: irregular heartbeats = palpitations
scribe writes, arrhythmia
41
Cardiac PMHx: pt says, murmur
scribe writes, heart murmur
42
Cardiac PMHx: pt says, episodes of abnormally fast/racing heartbeat
scribe writes, supraventricular tachycardia (SVT) *note: tachycardia = fast HR, >120bpm
43
Pulmonary PMHx: pt says, asthma
scribe writes, asthma
44
Pulmonary PMHx: pt says, emphysema/chronic bronchitis
scribe writes, chronic obstructive pulmonary disease (COPD)
45
Pulmonary PMHx: pt says, blood clot in lung
scribe writes, pulmonary embolism (PE)
46
Pulmonary PMHx: pt says, pneumonia
scribe writes, pneumonia (PNA)
47
Gastrointestinal PMHx: pt says, reflux
scribe writes, gastroesophageal reflux disease (GERD)
48
Gastrointestinal PMHx: pt says, ulcer
scribe writes, gastric ulcer or peptic ulcer disease (PUD)
49
Gastrointestinal PMHx: pt says, pancreatitis
scribe writes, pancreatitis
50
Gastrointestinal PMHx: pt says, hepatitis
scribe writes, hepatitis A, hepatitis B, or hepatitis C
51
Gastrointestinal PMHx: pt says, diverticulitis
scribe writes, diverticulitis (inflammation/infection of diverticula-pockets on the colon-)
52
Gastrointestinal PMHx: pt says, Crohn's/UC
scribe writes, Crohn's disease or ulcerative colitis
53
Gastrointestinal PMHx: pt says, irritable bowel
scribe writes, irritable bowel syndrome (IBS)
54
Genitourinary PMHx: pt says, bladder infection
scribe writes, urinary tract infection (UTI)
55
Genitourinary PMHx: pt says, kidney infection
scribe writes, pyelonephritis (Pyelo)
56
Genitourinary PMHx: pt says, kidney stones
scribe writes, renal calculi
57
Genitourinary PMHx: pt says, "I'm on dialysis"
scribe writes, chronic renal failure (CRF) on dialysis or end state renal disease (ESRD)
58
Genitourinary PMHx: pt says, enlarged prostate
scribe writes, benign prostatic hypertrophy (BPH) | *note: Benign = not harmful , Hypertrophy = enlarged
59
Gynecological PMHx| G: P: A: definition and meaning?
G: Gravida - total number of times the patient has been pregnant P: Para - number of pregnancies that resulted in birth A: Abortion - total number of miscarriages or elective abortions
60
Neurological PMHx: patient says, brain bleed (stroke)
scribe writes, hemorrhagic CVA
61
Neurological PMHx: patient says, stroke
scribe writes, ischemic cerebrovascular accident (CVA) | *note: ischemia = lack of blood supply
62
Neurological PMHx: patient says, mini-stroke
scribe writes, transient ischemic attack (TIA)
63
Neurological PMHx: patient says, seizures
scribe writes, history of seizures *note: there is a difference between history of seizures and the diagnosis of epilepsy: seizures can be acute and provoked (caused by a known reason) while epilepsy is classified by two or more seizures, the reason for which is unknown
64
Psychological PMHx: patient says, bipolar
scribe writes, bipolar disorder
65
Psychological PMHx: patient says, schizophrenia
scribe writes, schizophrenia
66
Psychological PMHx: patient says, “I drink a lot”
scribe writes, ETOH abuse or alcoholism
67
Psychological PMHx: patient says, “I do drugs”
scribe writes, substance abuse
68
Vascular PMHx: patient says, “Blood clot in my leg” vascular = relating to vessel(s) which carry blood, aka blood vessels (i.e. veins, arteries)
scribe writes, lower extremity deep vein thrombosis (DVT)
69
Vascular PMHx: patient says, “Bulge in my aorta”
scribe writes, aortic aneurysm
70
Vascular PMHx: patient says, “Bad flow to my legs”
scribe writes, peripheral vascular disease (PVD)
71
Vascular PMHx: patient says, “Numbness in my legs”
scribe writes, peripheral neuropathy
72
Musculoskeletal PMHx: patient says, low back pain
scribe writes, chronic low back pain
73
Musculoskeletal PMHx: patient says, bulging/herniated disc
scribe writes, degenerative disc disease (DDD)
74
Musculoskeletal PMHx: patient says, arthritis
scribe writes: - usually, osteoarthritis (OA) - sometimes, rheumatoid arthritis (RA) * note: RA is an autoimmune arthritis (immune sys. attacks lining of joints)
75
Musculoskeletal PMHx: patient says, weak/fragile bones
scribe writes: | - often, osteoporosis
76
Cancer PMHx: patient says, cancer
scribe writes, cancer or carcinoma (CA): brain, breast, lung, colon, prostate, ovary, skin, bone, leukemia, or lymphoma *note: CA is used for cancer or carcinoma
77
Cancer PMHx: patient says, “Spread to my....”
scribe writes: with metastasis to the...
78
Cancer PMHx: patient says, chemo
scribe writes, chemotherapy
79
Cancer PMHx: patient says, radiation
scribe writes, radiation therapy
80
Cancer PMHx: patient says, “They cut it out”
scribe writes, status post surgical resection
81
Cancer PMHx: patient says, “It’s gone”
scribe writes, in remission
82
PMHx
Past Medical History
83
PSHx
Past Surgical History
84
FHx
Family History
85
suffix -ectomy
surgical removal
86
suffix -otomy
opening of the skin; cutting into a part of the bosy
87
ENT PSHx: patient says, tonsils removed *note: ENT = ear, nose, and throat
scribe writes, tonsillectomy
88
ENT PSHx: patient says, adenoids removed
scribe writes, adenoidectomy
89
ENT PSHx: patient says, ear tubes
scribe writes, myringotomy or pressure equalizing (P.E.) tubes
90
Cardiovascular PSHx: patient says, heart bypass
scribe writes, coronary artery bypass graft (CABG) --> PMHx CAD
91
Cardiovascular PSHx: patient says, stents
scribe writes, coronary stents --> PMHx CAD
92
Cardiovascular PSHx: patient says, heart cath
scribe writes, cardiac catherterization
93
Cardiovascular PSHx: patient says, balloon
scribe writes, angioplasty --> PMHx CAD
94
Cardiovascular PSHx: patient says, valve surgery
scribe writes, valve repair or replacement (Bovine vs. Mechanical)
95
Cardiovascular PSHx: patient says, pacer
scribe writes, pacemaker
96
Cardiovascular PSHx: patient says, defibrillator
scribe writes, automatic implanted cardiac defibrillator (AICD)
97
Cardiovascular PSHx: patient says, surgery for Afib *note: Afib = atrial fibrillation
scribe writes, Afib s/p cardiac ablation
98
Pulmonary/Chest PSHx: patients says, breast removal
scribe writes, mastectomy
99
Pulmonary/Chest PSHx: patients says, hole in my neck
scribe writes, tracheotomy (commonly called a "trach")
100
Pulmonary/Chest PSHx: patients says, part of my lung removed
scribe writes, partial lobectomy
101
Gastrointestinal PSHx: patients says, appendix removed
scribe writes, appendectomy
102
Gastrointestinal PSHx: patients says, gallbladder removed
scribe writes, cholecystectomy
103
Gastrointestinal PSHx: patients says, hernia repair
scribe writes, herniorrhaphy
104
Gastrointestinal PSHx: patients says, part of my colon removed
scribe writes, partial colectomy
105
Gastrointestinal PSHx: patients says, bag to collect stool
scribe writes, colostomy
106
Gastrointestinal PSHx: patients says, spleen removed
scribe writes, splenectomy
107
Gastrointestinal PSHx: patients says, stomach stapled
scribe writes, bariatric surgery (gastric sleeve, gastric band/lap/band, gastric bypass, etc.)
108
Gastrointestinal PSHx: patients says, exploratory
scribe writes, exploratory laparoscopy (Ex Lap)
109
Genitourinary PSHx: patients says, kidney removed
scribe writes, nephrectomy
110
Genitourinary PSHx: patients says, uterus removed
scribe writes, hysterectomy (partial vs. total)
111
Genitourinary PSHx: patients says, ovary removed
scribe writes, oophorectomy
112
Genitourinary PSHx: patients says, ovary and fallopian tubes removed
scribe writes, salpingo-oophorectomy
113
Genitourinary PSHx: patients says, tubes tied
scribe writes, tubal ligation (female) or vasectomy (male)
114
Genitourinary PSHx: patients says, C-section
scribe writes, cesarean section
115
Genitourinary PSHx: patients says, prostate removed
scribe writes, prostatectomy or prostate resection (most often Transurethral Resection of the prostate, or TURP)
116
Genitourinary PSHx: patients says, uterine product removed
scribe writes, dilation and curettage (D&C)
117
Neurological PSHX: patient says, neck artery cleaned
scribe writes, carotid endarterectomy
118
Neurological PSHX: patient says, shunt
scribe writes, cerebral shunt
119
Neurological PSHX: patient says, brain surgery
scribe writes, craniotomy (brain bleed vs. brain CA)
120
Vascular PSHX: patient says, dialysis fistula
scribe writes, AV (arteriovenous fistula)
121
Vascular PSHX: patient says, dialysis graft
scribe writes, AV graft
122
Vascular PSHX: patient says, PICC Line
scribe writes, peripherally inserted central catheter (PICC)
123
Vascular PSHX: patient says, port
scribe writes, Port-a-cath or Medi-Port
124
Vascular PSHX: patient says, clot filter (lower abdomen or leg)
scribe writes, IVC (inferior vena cava) filter
125
Orthopedic PSHx: patient says, leg amputated
scribe writes, above knee amputation (AKA) or below knee amputation (BKA)
126
Orthopedic PSHx: patient says, joint repair
scribe writes, arthroplasty
127
Orthopedic PSHx: patient says, metal plates/pins
scribe writes, hardware
128
Orthopedic PSHx: patient says, neck fused
scribe writes, cervical spinal fusion
129
Orthopedic PSHx: patient says, back fused
scribes writes, spinal fusion
130
Orthopedic PSHx: patient says, new hip
scribe writes, total hip replacement
131
home medication and allergies are usually documented by the nurse of MA, not the scribe
***Any medication that causes a rash, itching, swelling, or difficulty breathing is a true allergy; any other response is an "adverse" reaction***
132
Family History (FHx) important info
- age of onset for each dz is very important to Fx b/c it helps determine the genetic risk factors - **a younger age of onset means higher genetic risk - older age of onset is more likely due to environment than genetics - genetic risk for a dz is higher if multiple blood related family members suffer from the same disease
133
general FHx (physicians commonly ask about)
HTN, DM, CA
134
cardiac FHx
MI/CAD less than 55 y/o
135
pulmonary FHx
PE, asthma
136
gastrointestinal FHx
Crohn's, IBS
137
neurological FHx
CVA, aneurysm, seizures
138
miscellaneous FHx
sickle cell anemia, DVT
139
5 categories of social history (SHx)
tobacco use, alcohol use (ETOH), illicit drug use, occupation, living circumstances
140
SHx on tobacco use note: if your clinic reports smoking cessation as a quality measure, it is required that smoking status is documented on every patient 13 y/o and up
1. smoking status - current (#ppd, #yrs) - former (year quit) - never - second smoke exposure (ped) - E-cigarettes 2. chewing tobacco
141
SHx on alcohol use
1. never 2. occasionally/socially 3. daily 4. chronic alcoholic - number of drinks/day - type of alcohol (beer/wine/liquor)
142
SHx on illicit drug use
1. which drug - heroin - cocaine - methamphetamine - THC - narcotics 2. route of administration - oral - inhaled - injected 3. date of last use
143
SHx on occupation
1. employed 2. unemployed 3. on disability 4. retired *if a physician asks specifically about a type of work, be sure to document it
144
SHx on living circumstances
1. lives alone 2. with family/friends 3. nursing home/assisted living 4. hospice 5. homeless/shelter
145
Pediatric SHx *there are a few social history components that are unique to pediatric patients as they often cannot verbalize their home/life situation
1. caretaker (mother, father, grandparent) 2. attend daycare 3. attend school 4. have brothers/sisters 5. second-hand smoke exposure 6. immunizations up-to-date

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