OP 1: Patient History Flashcards
What is a HealthChannels Identity?
This is a Google identity which allows you to log in to all our company’s systems (Workday, scheduling, training, etc.) with one username and password.
What is the role of a scribe?
Scribes intelligently share the clinician’s burden of data gathering and chart documentation.
What are some tasks a scribe CAN complete?
- 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 EGCs
What are some tasks a scribe CAN NOT complete?
- Touch/evaluate patients
- Write orders/prescriptions
- Give verbal orders
- Sign/authenticate and chart or record on behalf of the provider
- Handle bodily fluids or specimens
Y/N: Your provider si tied up in a procedure, so he asks you to tell the nurse to draw up 4mg of morphine for the patient. Is this within the scope of a scribe?
No
What are true perks to becoming a scribe?
- Learn about medicine
- Learn hoe to document like a clinician
- Gain first hand 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 visit
Subjective
How the patient is feeling (i.e. pain - the patients feeling and level of discomfort)
Objective
Factual findings from the provider (i.e. tenderness - doctors finding of reproducible pain)
Acute
New onset, likely concerning
Chronic
Long-standing, not of direct concern
New Patient Visit
A visit in which the patient has never been seen at the clinic, or was seen over 3 years ago. There is typically no previous records, longer visit, and a detailed chart.
Established Patient Visit
A visit in which the patient has been seen at the clinic, by any provider, within the last 3 years. There will be previous records available, visits will be shorter, and chart will be concise.
Diagnostic Visit
A visit in which there is a new problem with new symptoms and the goal is to determine the cause of the problem and appropriate treatment.
Health Management Visit
A check up visit which usually addresses routine physicals or the management of chronic problems. The goal of a health management visit is preventative care and/or addressing the progress of ongoing medical problems.
Clinic Flow
- Check In and Chief Complaint
- History and Physical
- Orders and Results
- Assessment and Plan
- Check Out
What is completed during check in?
- Patient arrives
- Patient is assigned a room
- Nurse confirms chief complaint
- Nurse will obtain vital signs (HR, BP, RR - respiratory rate, Temp, and O2)
- Obtain height, weight, smoking/alcohol status, review allergies and medications
What is completed during history and physical?
- Provider reviews member chart prior to entering the room
- Provider reviews history of present illness (HPI), review of systems (ROS), past history, physical exam.
- For diagnostic visits provider will also provide a differential diagnosis (DDx - possible causes of patients chief complaint)
What is completed during orders and results?
- Provider will order or give results of labs (bloodwork, urinalysis, microscopy, cultures, etc.)
- Provider will order or give results of imaging studies (EKG, X-Ray, CT, ultrasound, etc.)
- Provider will order procedures (sutures, joint reduction, splints, etc.)
What is completed during assessment and plan?
- Provider will give a list of current diagnoses
- Provider will give a summary of the visit
- Provider will cover the treatment plan (instructions for lifestyle changes, medications, surgery, follow-up, etc.)
What is completed during check out?
- Patient will either be sent home or ED
- Patient is provided with education
- Patient will often stop at the front desk on the way out to schedule next appointment
How are patient visits documented?
Through the use of SOAP notes:
- S (subjective complaints): HPI and ROS
*Past History (4 parts: medical, surgical, social, family)
- O (objective evaluation): Physical Examination (PE) and Orders/Results
- A (assessment): Current Diagnosis
- P (plan): Treatment Plan and Follow-Up
Layman’s Terms
What the patient will likely call the disease.
Medical Term
What the provider/scribe will document the disease as.
High Blood Pressure
Hypertension (HTN)
High Cholesterol
Hyperlipidemia (HLD)
Diabetes
Diabetes Mellitus (DM)
What does a patient have when they say ‘I only take pills for my diabetes’?
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
What does a patient have when they say ‘I only take shots/insulin for my diabetes’?
Insult Dependent Diabetes Mellitus (IDDM)
Heart Disease
Coronary Artery Disease (CAD)
