Week 1 - Patient Health History

Question 1

Give some examples of what is out of scope for scribes?

Answer 1

Touch patients

Write orders or prescriptions

Give verbal orders

Sign or authenticate any chart or record

Handle bodily fluids or specimens

Question 2

What do you call the main reason for the patient’s emergency visit?

Answer 2

Chief complaint

Question 3

EMR/EHR

Answer 3

Electronic medical record/electronic health record

Question 4

Difference between subjective and objective

Answer 4

Feelings from the patient

Factual findings from the provider

Question 5

Difference between pain and tenderness

Answer 5

Patient’s feeling of discomfort

Doctor’s finding of reproducible pain

Question 6

Difference between acute and chronic

Answer 6

New onset, likely concerning

Long-standing, not of direct concern

Question 7

What is the emergency department flow?

Answer 7

Check In & Triage

History & Physical

Differential Diagnosis

Orders & Treatment

Medical Decision Making

Disposition

Question 8

What are the main vital signs and their abbreviations?

Answer 8

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

Level of Acuity: 1 (High) to 5 (Low)

Question 9

When does the scribes documentation begin?

Answer 9

The HPI and ROS (after the nurse assessment)

History of Present Illness and Review of Systems

Question 10

What will the physician do with the H&P?

Answer 10

These leads to differential diagnoses (DDx)

The physician generaties a list of things that MAY be causing the patient’s subjective symptoms.

Then the doctor places orders to “rule out” each differential.

Question 11

What are types of lab studies the physician may order?

Answer 11

Blood work, urinalysis, microscopy, cultures

Question 12

What are types of imaging studies the physician may order?

Answer 12

EKG/ECG, X-Ray, CT, Ultrasound

Question 13

What are types of procedures the physician may order?

Answer 13

Sutures, joint reduction, splints

Question 14

What are types of medications the physican may order?

Answer 14

Antiemetics, analgesics, vasodilators, diuretics, antibiotics.

Antiemetics are used to prevent or treat nausea and vomitting.

Analgesics are painkillers and pain medications aimed at redcucing pain.

Vasodilators are meds that open or dilate blood vessels especially in high blood pressure events.

Diuretics help rid body of water and sodium. This increase salt production of the liver, removing excess water from the blood, decreasing the amount of fluid flowing through your veins and arteries which reduces blood pressure.

Antibiotics are medicines that fight bacterial infections in people and animals.

Question 15

What comes after the orders and treatment for the emergency department flow for a specific patient?

What comes after this?

Answer 15

The medical decision making (MDM) consists of the diagnosis or treatment plan. (discharged, admitted, trasnferred, left AMA (against medical advice), expired)

The disposition of the patient comes after the MDM.

Question 16

What do the subjective complaints consist of?

What does the objective evaluation consist of?

Answer 16

HPI/ROS

Physical exam/Orders and Treatment

Question 17

PMHx The Most Common

high blood pressure

Answer 17

Hypertension (HTN)

Question 18

PMHx The Most Common

high cholesterol

Answer 18

Hyperlipidemia (HLD)

Question 19

PMHx The Most Common

Diabetes

Answer 19

Diabetes Mellitus (DM)

Question 20

PMHx The Most Common

I only take pills for my diabetes

Answer 20

Non-insulin dependent diabetes mellitus (NIDDM)

Question 21

PMHx The Most Common

I take shots (insulin) for my diabetes

Answer 21

Insulin dependent diabetes mellitus (IDDM)

Question 22

PMHx Cardivascular

heart disease

Answer 22

Coronary Artery Disease (CAD)

Question 23

PMHx Cardivascular

heart attack

Answer 23

Myocardial Infarction (MI) and CAD

Question 24

PMHx Cardivascular

heart failure

Answer 24

Congestive Heart Failure (CHF)

Question 25

PMHx Cardivascular irregular heartbeat

Answer 25

Arrhythmia

Question 26

PMHx Pulmonary asthma

Answer 26

Asthma

Question 27

PMHx Pulmonary Emphysema or chronic bronchitis

Answer 27

Chronic Obstructive Pulmonary Disease (COPD)

Question 28

PMHx Pulmonary Blood clot in lung

Answer 28

Pulmonary Embolism (PE)

Question 29

PMHx Pulmonary Pneumonia

Answer 29

Pneumonia (PNA)

Question 30

PMHx Gastrointestinal Reflux

Answer 30

Gastroesophageal Reflux Disease (GERD)

Question 31

PMHx Gastrointestinal Ulcers

Answer 31

Gastric Ulcer or Peptic Ulcer Disease (PUD)

Question 32

PMHx Gastrointestinal Pancreatitis

Answer 32

Pancreatitis

Question 33

PMHx Gastrointestinal Hepatitis

Answer 33

Hepatitis

Question 34

PMHx Gastrointestinal Irritable bowel

Answer 34

Irritable Bowel Syndrome (IBS)

Question 35

PMHx Genitourinary Bladder infection

Answer 35

Urinary Tract Infection (UTI)

Question 36

PMHx Genitourinary Kidney infection

Answer 36

Pyelonephritis

Question 37

PMHx Genitourinary Kidney stones

Answer 37

Renal Calculi

Question 38

PMHx Genitourinary I'm on dialysis

Answer 38

Chronic Kidney Disease (CKD) on dialysis

Question 39

PMHx Genitourinary enlarged prostate

Answer 39

Benign Prostatic Hyperplasia (BPH)

Question 40

PMHx Gynecological What is the convention for documentating past pregnancies, births, and abortions that you must be familiar with? This is considered a pertinent part of PMHx for any female patient.

Answer 40

The convention is known as G: P: A: - Gravida "G" is the total number of times the patient has been pregnant - Para "P" is the number of pregnancies that resulted in viable births - Abortus "A" is the total number of miscarriages or elective abortions

Question 41

PMHx Vascular Stroke Blockage in the Brain Brain bleed

Answer 41

Cerebrovascular Accident (CVA) Ischemic CVA Hemorrhagic CVA

Question 42

PMHx Vascular "Mini stroke" Blood clot in my leg "Bulge in my aorta" "Bad blood flow in my legs"

Answer 42

Transcient Ischemic Attack (TIA) Deep vein thrombosis (DVT) Aortic Aneurysm Peripheral Vascular Disease (PVD)

Question 43

What do these abbreviations mean? History information is not always relevant to the chief complaint, so we place all history infor in the PHx which includes PMHx, PSHx, SHx, and FHx

Answer 43

PHx = Past History sections PMHx = Past Medical History PSHx = Past Surgical History SHx = Social History PHx = Family History

Question 44

What does the following mean? itis osis ectomy nephr chole mast hepa

Answer 44

itis is inflammation osis is disease ectomy is surgical removal nephr is kidneys/renal (renal relates to the FUNCTION of kidneys) chole is gallbladder mast is breasts hepa is liver

Question 45

Translate the following laymen speak of past surgical history: Tonsils removed Adenoids removed Ear Tubes

Answer 45

Tonsillectomy Adenoidectomy Pressure Equalizer (P.E.) Tubes

Question 46

Translate the following laymen speak of past surgical history (PSHx): "balloon in my heart" "Stents in my heart" Heart bypass breast removal Part of my lung removed

Answer 46

Angioplasty ---> PMHx CAD Coronary Stents ----> PMHx CAD Coronary Artery Bypass Graft (CABG) ----> PMHx CAD Masectomy Partial Lobectomy

Question 47

Translate the following laymen speak of past surgical historys (PSHx) for the GI: Appendix removed Gallbladder removed Part of my colon removed Spleen removed Kidney removed

Answer 47

appendectomy cholecystectomy partial colectomy splenectomy nephrectomy

Question 48

Translate the following laymen speak of past surgical historys (PSHx) for the GU: Uterus removed Ovary removed Ovary and fallopian tube removed Prostate removed

Answer 48

Hysterectomy Oophorectomy Salpingo-oophorectomy Prostatectomy

Question 49

What does family history or FHx pertain to when determining genetic risk factors?

Answer 49

Parents and grandparents to include siblings.

Question 50

What is the age of onset for disease that means higher genetic risk?

Answer 50

Under 55

Question 51

What are some things that consist of Social history or SHx?

Answer 51

Tobacco/Alcohol/Drug Use Occupation Living Circumstances

Question 52

Why should you pay attention to medications?

Answer 52

It can tell you a lot about past medical history

Question 53

What is a true allergy to a medication defined as?

Answer 53

Medication that causes itching, swelling, difficulty breathing or rash. Otherwise it is an "adverse reaction," not a true allergy.

Question 54

Top 10 key things to document as a scribe! (No Answer) A provider's INVESTIGATION of ptx 1. Reviewing external records (notes or summaries from other hospitals or EMS) 2. Documenting independent historians (history obtained other than the pt) 3. Capturing chronic illnesses (listing comorbidities, differential dx, risk assessments) A provider's ACTIONS 1. When drugs require intensive monitoring (what medications given and when, including any follow up) 2. Independent interpretations by your provider (live discussions with other providers about test results) 3. Test interpretations discussed with external provider (live discussions with other providers about test results) A provider's CONSIDERATIONS 1. Considerations of admission or escalation of care (why a pt was escalated to ICU or considered safe to go home) 2. Considerations of diagnostic tests even if not done (considering one test over another and why it was done or not. Such as CT scans) 3. Prescription medications given or considered (Documenting meds considered like antibiotics even if not given, and reason) 4. If patient care is affected by social determinations (documenting if a plan of care was changed or determined because of social factors that may impact health.

Answer 54

No Answer

Question 55

Why is it so important to document everything?

Answer 55

To bill correctly, and for legal/historical reasons