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Scribe America > Outpatient: Welcome and patient health history > Flashcards

Outpatient: Welcome and patient health history Flashcards

1
Q

Chief Complaint

A

The main reason for the patient’s outpatient visit

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2
Q

EMH/EHR

A

Electronic medical record/electronic health record

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3
Q

Subjective

A

Feeling

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4
Q

Objective

A

Factual finding from the provider

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5
Q

Pain

A

Patient’s feeling of discomfort

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6
Q

Tenderness

A

Doctor’s finding of reproducible pain

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7
Q

Acute

A

New onset. likely concerning

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8
Q

Chronic

A

Long-standing. not of direct concern

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9
Q

New Patient

A

A patient that has never been seen at the clinic, or was seen greater than 3 years ago
-No previous records
-Longer visit
-Detailed chart

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10
Q

Established Patient

A

A patient that has been seen at the clinic (by any provider) within the last 3 years
-Previous records available
-Shorter visit
-Concise chart

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11
Q

Diagnostic Visit

A

-New problem
-Chief complaint (CC): New symptom
-Goal is to determine the cause of the problem and appropriate treatment

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12
Q

Health Management Visit

A

-Check-up
-CC: Routine physical management of chronic problems
-Goal is preventative care and/or assessing progress of ongoing medical problems

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13
Q

What is the clinic flow?

A

-Check in & CC
-History and Physical
-Orders and results
-Assessment and plan
-Checkout

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14
Q

What are the vital signs?

A

-HR: Heart Rate (bpm)
-BP: Blood Pressure (mmHg)
-RR: Respiratory rate
-T: Temperature (C or F)
-SaO2: Oxygen Saturation (%)

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15
Q

What is done before entering the room between scribe and provider?

A

Provider will review the patient’s medical records
-Assessment and plan from prior visit
-Labs and/or imagining results

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16
Q

What is included in History and Physical (H&P)

A

History of present illness (HPI)
Review of systems (ROS)
Past History
Physical Exam (PE)

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17
Q

Differential Diagnosis (DDx)

A

List of possible Dx that could be causing patient’s complaints

ONLY FOR DIAGNOSTIC VISITS

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18
Q

Physician Orders

A

-Laboratory Studies: Blood work, urinalysis, Microscopy, Cultures
-Imaging Studies: EKG, X-RAY, CT, Ultrasound
-Procedures: Sutures, Join reduction, Splints

Results may result during visit (rare) or in a few days

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19
Q

Physician Assessment

A

The list of current diagnoses and summary of visit

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20
Q

Physician Plan

A

Treatment Plan:
-Instructions for lifestyle changes
-Medications
-Follow-up

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21
Q

Check-out

A

-Home vs sent to ER
-Patient education provided
-Patient will often stop at the front desk on the way out to schedule next appointment

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22
Q

S (Subjective Complaints)

A

HPI: Hx of present illness
ROS: Review of systems
Past hx

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23
Q

O (Objective Evaluation)

A

PE: Physical Exam
Orders and Results

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24
Q

A (Assessment)

A

Assessment (current diagnoses)

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25
Q

P (Plan)

A

Plan (Treatment plan and follow up)

26
Q

HPI

A

History of present illness
-the story and context of the CC

27
Q

ROS

A

Review of systems
-A head-to-toe list of positive and negatives

28
Q

Past History

A

-Medical
-Surgical
-Social
-Family

29
Q

Where is patient complaint charted?

A

HPI or ROS

30
Q

Where is past diagnosis/surgeries charted?

A

Past history

31
Q

Where is Physician’s observations charted?

A

Physical Exam

32
Q

Where are lab’s, imaging, and studies charted?

A

Results

33
Q

Where are current diagnosis charted?

A

Assessment

34
Q

Where is the treatment plan charted?

A

Plan

35
Q

What are the three important things to know about each disease?

A

-Layman’s terms
-Medical term
-The abbreviation

36
Q

HTN (hypertension)

A

High Blood Pressure

37
Q

Hyperlipidemia (HLD)

A

High Cholesterol

38
Q

Diabetes Mellitus (DM)

A

Diabetes

39
Q

“I only take pills for my diabetes”

A

Non-insulin dependent diabetes mellitus (NIDDM)

40
Q

“I take shots (insulin) for my diabetes”

A

Insulin dependent diabetes mellitus (IDDM)

41
Q

“I’m on dialysis”

A

Chronic Kidney Disease (CKD) on dialysis

42
Q

“Enlarged Prostate”

A

Benign Prostatic hyperplasia (BPH)

43
Q

“Blood clot in the brain”

A

Ischemic CVA

44
Q

“Mini Stroke”

A

Transient Ischemic Attack (TIA)

45
Q

“Blood clot in my leg”

A

Deep vein thrombosis (DVT)

46
Q

“Bulge in my aorta”

A

Aortic Aneurysm

47
Q

“Bad blood flow in my legs”

A

Peripheral Vascular disease (PVD)

48
Q

Cancer

A

Cancer or carcinoma (CA)

49
Q

“Spread to my…”

A

With metastasis to the…

50
Q

Chemo

A

Chemotherapy

51
Q

Radiation

A

Radiation therapy

52
Q

“They cut it out”

A

Status-post surgical resection

53
Q

“Its gone” in regard to cancer

A

In remission

54
Q

What are the four symptoms or a true allergy

A

-rash
-itching
-swelling
-difficulty breathing

55
Q

Ectomy suffix

A

removal

56
Q

Leg amputation

A

Above knee amputation (AKA)
Below Knew amputation (BKA)

57
Q

“Balloon in my heart”

A

Angioplasty xCAD

58
Q

“Stents in my heart”

A

Coronary stents xCAD

59
Q

Heart Bypass

A

Coronary Artery Bypass Graft CABG xCAD

60
Q

A younger age onset of __ means higher genetic risk

A

under 55

61
Q

Social History (SHx)

A

Alcohol Use
Tobacco Use/Vaping
-PPD
Drug use
Occupation
Living Circumstances

62
Q
A

Scribe America (4 decks)

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