Outpatient Course 1 – Flashcards
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Midlevel Provider
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Nurse Practitioner (LNP) or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients.
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Nurse or Medical Assistant
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Records medical histories and symptoms, monitors the patient, completes meaningful use requirements, administers medications, assists with procedures.
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Scribes CAN:
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Document hx, physical exam, results, procedures, assessment, and plan. Access & document lab results and radiology findings. Locate & obtain PMHx, previous charts, past results, and recent studies. Record physician interpretations of x-rays and EKGs.
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Scribes CANNOT:
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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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Are physician assistants and nurse practitioners considered medical providers?
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No.
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T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning purposes and under supervision of the physician.
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False.
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What will the scribe document for the outpatient visit?
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Important notes for past medical histories. History and physical. Lab and radiology results. Physician interpretation of XRs and EKGs.
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Subjective
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Feeling
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Objective
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Fact
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Pain vs. Tenderness
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Patient's feeling vs. physician's assessment
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Benign
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Normal, nothing of concern
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Acute
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New onset
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Chronic
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Long standing
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Baseline
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An individual's normal state of being
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Auscultation
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Listening with a stethoscope
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Palpation
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The act of pressing on an area (by the physician)
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Inpatient
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Admitted to the hospital overnight
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Outpatient
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Seen and sent home the same day
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Chief complaint
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The main reason for the patient's visit
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Meaningful Use
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A set of government mandated criteria that must be obtained for every patient.
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Medical Decision Making
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The physician's thought process
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New Patient
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No previous records, longer visit, detailed chart
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Established Patient
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Previous records available, seen in the last 3 years, shorter visit, concise chart
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Diagnostic Visit
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New Problem Chief Complaint: New Symptom Goal is to determine the cause of the problem and appropriate treatment
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Health Maintenance Visit
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Check-up Chief Complaint: Management of ________ Goal is to assess progress of on-going/chronic medical problems
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Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine appointment with Dr. Heart. Is Lucy a new or established patient?
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Established.
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A patient made an appointment because she developed a rash a few days ago. What type of visit would this be?
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Diagnostic.
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A patient has an appointment for management of her diabetes. What type of visit would this be?
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Health Maintenance
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Clinic Flow
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Check-In Physician Evaluation Orders & Results Assessment & Plan Check-Out
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Meaningful Use obtained by Nurse/MA
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Chief Complaint Vital Signs: HR, BP, T, RR Height, weight, BMI Smoking status
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Nurse/MA assessment
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Confirm chief complaint Review allergies/medications Brief past medical history
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Who is the first person to speak with the patient after he/she is placed in a room?
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Nurse/MA
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What are the meaningful use requirements the Nurse/MA will obtain?
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Chief Complaint, vitals, height, weight, BMI, and smoking status
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What does H & P abbreviate and who performs this evaluation?
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History and Physical performed by the physician.
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Is a differential diagnosis necessary for a health maintenance visit?
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No. Only for a diagnostic visit.
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What information will be included in the patient's plan?
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Follow-up w/ specialist if necessary. Instructions for lifestyle and preventative care. Follow-up for next routine appointment.
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What does SOAP stand for?
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Subjective, Objective, Assessment, Plan
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Subjective
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History of present Illness (HPI) Review of Systems (ROS)
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Objective
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Physical Examination (PE) Orders & Results
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Hypertension (HTN)
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"High Blood Pressure"
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Hyperlipidemia (HLD)
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"High Cholesterol"
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Hypothyroidism or Hyperthyroidism
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"Thyroid Problem"
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Non-Insulin Dependent Diabetes Mellitus (NIDDM)
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"I only take pills for my diabetes"
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Insulin Dependent Diabetes Mellitus (IDDM)
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"I take shots (insulin) for my diabetes"
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Coronary Artery Disease (CAD)
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"Heart Disease"
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Myocardial Infarction (MI) and CAD
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"Heart Attack"
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Atrial Fibrillation (A-Fib)
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"Irregular Heartbeat"
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Supraventricular Tachycardia (SVT)
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"Episodes of abnormally fast/racing heartbeats"
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Chronic Obstructive Pulmonary Disease (COPD)
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"Emphysema/Chronic Bronchitis"
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Pulmonary Embolism (PE)
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"Blood clot in lung"
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Gastroesophageal Reflux Disease (GERD)
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"Reflux"
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Gastric Ulcer or Peptic Ulcer Disease (PUD)
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"Ulcer"
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Pyelonephritis (Pyelo)
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"Kidney Infection"
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Renal Calculi
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"Kidney Stones"
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Chronic Renal Failure (CRF) on dialysis
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"I'm on dialysis"
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Benign Prostatic Hypertrophy (BHI)
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"Enlarged prostate"
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G
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Total number of times the patient has been pregnant
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P
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Number of live births (viable children) that the pt has had
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A
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Total number of miscarriages or elective abortions
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Transient Ischemic Attack (TIA)
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"Mini-stroke"
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Cerebrovascular Accident (CVA)
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"Stroke"
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Hemorrhagic CVA
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"Brain Bleed"
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Lower Extremity DVT
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"Blood clot in my leg"
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Abdominal Aortic Aneurysm (AAA)
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"Bulge in my aorta"
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Peripheral Vascular Disease (PVD)
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"Bad blood flow to my legs"
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Degenerative Disc Disease (DDD)
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"Bulging/Herniated Disc"
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Chronic Low Back Pain
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"Low Back Pain"
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Degenerative Joint Disease (DJD)
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"Chronic Joint Pain"
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Tonsillectomy
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Tonsils removed
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Adenoidectomy
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Adenoids Removed
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Pressure Equalizer (P.E.) Tubes
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Ear Tubes
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Mastectomy
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Breast Removal
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Tracheostomy (commonly called a "trach")
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"Hole in my neck"
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Partial Lobectomy
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Part of my lung removed
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Appendectomy
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Appendix Removed
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Cholecystectomy
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Gallbladder Removed
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Herniorrhaphy
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Hernia Repair
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Partial Colectomy
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"Part of my colon removed"
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Splenectomy
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Spleen Removed
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Gastric Bypass
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Stomach stapled
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Colostomy
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Bag to collect stool
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Hysterectomy
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Uterus Removed
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Oophorrectomy
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Ovary Removed
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Salpingo-oophorrectomy
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Ovary and fallopian tubes removed
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Tubal Ligation (female) or vasectomy (male)
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Tubes tied
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Casarean Section
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C-Section
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Prostatectomy (most often Trans-Urethral Resection of the Prostate, or TURP)
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Prostate Removed
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Carotid Endarterectomy
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Neck artery cleaned
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Craniotomy
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Brain surgery
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Ventriculoperitoneal (VP) shunt
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Shunt
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Peripherally Inserted Central Catheter (PICC)
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PICC Line
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AV Graft
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Dialysis Graft
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AV (arteriovenous) Fistula
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Dialysis Fistula
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IVC (inferior vena cava) filter
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Clot filter (lower abdomen)
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Arthroplasty
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Joint Repair
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Hardware
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Metal plates/pins
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Cervical Spinal Fusion
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Neck fused
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Lumbar Spinal Fusion
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Back fused
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At what age would a family member's cardiac disease indicate an increased risk for similar heart disease in the patient?
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50 or younger
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What are three common general family histories your physician may ask you?
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High Blood Pressure Diabetes Cancer
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Would PMHX of chronic alcoholism belong in the SHx section as well as the PMHx section?
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No?
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Why must smoking status be documented on every patient 13 years and older?
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Meaningful Use Requirement
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Name the three most common routes of administration of illicit drugs.
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Oral, inhaled, or injected
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The patient's mother states, "The daycare called me to pick up Angela and her brother because Angela had a fever." What are three items you can document under social history for Angela?
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Caretaker Attends daycare Has a brother
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History of Present Illness (HPI)
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Subjective details of the chief complaint
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Review of Systems (ROS)
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Subjective head to toe overview of symptoms
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Physical Exam
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Objective doctor's assessment
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If the doctor tells you, "The lungs are clear," where would you document this?
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Physical Exam
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The patient explains that he was on a smoking break at work when he began to experience chest pain. Which of the following items could you include in his social history?
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Smoking Employed
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Give examples of living circumstances:
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Lives with family/friends Homeless/shelter Nursing home/assisted living Hospice Lives alone
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Meaningful Use
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Improve quality, safety and efficiency of patient care Engage patients and families Improve care coordination Ensure adequate privacy and security for personal health information Improve population and public health
