Scribe America Final Exam OP UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS
Subjective Patient feeling
objective provider fact
pain patient's feeling
, tenderness provider assessment
baseline an individual's normal state of being
auscultation listening with a stethoscope
palpation the act of pressing on an area by provider
inpatient admitted overnight
outpatient seen and sent home the same day
chief complaint main reason for patient's visit
meaningful use set of gov't mandated criteria that must be obtained for every patient
medical decision making physician's thought process
new patients longer visit, concise chart
established patients shorter visit, concise chart
diagnostic visit visit for a new problem; CC is a new symptom; determine cause of problem and
appropriate treatment
health maintenance visit check up; CC management of chronic problem; assess progress of
ongoing/chronic problem; preventative care
SOAP subjective, objective, assessment, plan
subjective section includes history of present illness, review of systems
history of present illness story and context of chief complaint
objective evaluation physical examination, orders and results
assessment section diagnoses
plan section treatment and follow up
"high blood pressure" hypertension - HTN
"high cholesterol" hyperlipidemia - HLD
"thyroid problem" hypothyroidism or hyper
"I only take pills for my diabetes" Non-Insulin dependent diabetes mellitus (NIDDM)
ANSWERS
Subjective Patient feeling
objective provider fact
pain patient's feeling
, tenderness provider assessment
baseline an individual's normal state of being
auscultation listening with a stethoscope
palpation the act of pressing on an area by provider
inpatient admitted overnight
outpatient seen and sent home the same day
chief complaint main reason for patient's visit
meaningful use set of gov't mandated criteria that must be obtained for every patient
medical decision making physician's thought process
new patients longer visit, concise chart
established patients shorter visit, concise chart
diagnostic visit visit for a new problem; CC is a new symptom; determine cause of problem and
appropriate treatment
health maintenance visit check up; CC management of chronic problem; assess progress of
ongoing/chronic problem; preventative care
SOAP subjective, objective, assessment, plan
subjective section includes history of present illness, review of systems
history of present illness story and context of chief complaint
objective evaluation physical examination, orders and results
assessment section diagnoses
plan section treatment and follow up
"high blood pressure" hypertension - HTN
"high cholesterol" hyperlipidemia - HLD
"thyroid problem" hypothyroidism or hyper
"I only take pills for my diabetes" Non-Insulin dependent diabetes mellitus (NIDDM)
