SCRIBEAMERICA OUTPATIENT UPDATED EXAM SCRIPT
QUESTIONS AND ANSWERS SURE A+
✔✔Health Management Visit - ✔✔Check-up, Chief Complaint: Routine physical or
management of chronic problem(s), and Goal is preventative care and/or assessing
progress of ongoing medical problems
✔✔CLINIC FLOW - ✔✔Check in -> Physical evaluation -> Orders & Results ->
Assessment & Plan -> Check Out
✔✔CLINIC FLOW - CHECK-IN - ✔✔Patient Walks in (Diagnostic vs. Health
Management) -> Room Placement -> Meaningful Use obtained by Nurse/MA (Chief
complaint, Vital signs: HR, BP, T, RR), Height, Weight, BMI, Smoking Status) ->
Nurse/MA Assessment (Confirm chief complaints, review allergies/medications , brief
past medical history)
✔✔CLINIC FLOW - PHYSICIAN EVAL - ✔✔Review the patient's medical records
(Assessment & plan from the previous visit, Labs and/or imaging results) -> History and
Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical
Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the
symptoms)
✔✔CLINIC FLOW - ORDERS & RESULTS - ✔✔Orders (Laboratory studies, Imaging
studies, and Procedures) -> Results (May result during visit (rare) or in a few days)
✔✔CLINIC FLOW - ASSESSMENT & PLAN - ✔✔Assessment (The list of diagnoses) ->
Plan (Follow-up with specialist if necessary, Instructions for lifestyle and preventative
care, and Follow-up for next routine appointment)
✔✔CLINIC FLOW - CHECK-OUT - ✔✔Check-out (Home vs. sent to the ED, Patient
education provided, and Patient will often stop at the front desk on the way out to
schedule next appointment)
✔✔SECTIONS OF A CHART - ✔✔S (Subjective), O (Objective), A (assessment), and P
(Plan)
✔✔Past diagnosis or surgery - ✔✔Past History
✔✔Physician's observation - ✔✔Physical Exam
✔✔High blood pressure - ✔✔Hypertension (HTN)
✔✔High cholesterol - ✔✔Hyperlipidemia (HLD)
, ✔✔Thyroid problem - ✔✔Usually Hypothyroidism, sometimes Hyperthyroidism
✔✔Diabetes - ✔✔Diabetes Mellitus (DM)
✔✔"I only take pills for my diabetes" - ✔✔Non-Insulin Dependent Diabetes Mellitus
(NIDDM)
✔✔"I take shots (insulin) for my diabetes" - ✔✔Insulin Dependent Diabetes Mellitus
(IDDM)
✔✔Heart disease - ✔✔Usually Coronary Artery Disease (CAD)
✔✔Heart attack - ✔✔Myocardial Infarction (MI) and CAD
✔✔Heart failure - ✔✔Congestive Heart Failure (CHF)
✔✔Irregular heartbeat - ✔✔Arrhythmia
✔✔Murmur - ✔✔Heart murmur
✔✔Episodes of abnormally fast/racing heartbeat - ✔✔Supraventricular Tachycardia
(SVT)
✔✔Emphysema/Chronic Bronchitis - ✔✔Chronic Obstructive Pulmonary Disease
(COPD)
✔✔Blood clot in lung - ✔✔Pulmonary Embolism (PE)
✔✔Pneumonia - ✔✔Pneumonia (PNA)
✔✔Reflux - ✔✔Gastroesophageal Reflux Disease (GERD)
✔✔Ulcer - ✔✔Gastric Ulcer or Peptic Ulcer Disease (PUD)
✔✔Hepatitis - ✔✔Hepatitis A, Hepatitis B, or Hepatitis C
✔✔Crohn's/UC - ✔✔Crohn's Disease or Ulcerative Colitis
✔✔Irritable bowel - ✔✔Irritable Bowel Syndrome (IBS)
✔✔Bladder infection - ✔✔Urinary Tract Infection (UTI)
✔✔Kidney infection - ✔✔Pyelonephritis (Pyelo)
QUESTIONS AND ANSWERS SURE A+
✔✔Health Management Visit - ✔✔Check-up, Chief Complaint: Routine physical or
management of chronic problem(s), and Goal is preventative care and/or assessing
progress of ongoing medical problems
✔✔CLINIC FLOW - ✔✔Check in -> Physical evaluation -> Orders & Results ->
Assessment & Plan -> Check Out
✔✔CLINIC FLOW - CHECK-IN - ✔✔Patient Walks in (Diagnostic vs. Health
Management) -> Room Placement -> Meaningful Use obtained by Nurse/MA (Chief
complaint, Vital signs: HR, BP, T, RR), Height, Weight, BMI, Smoking Status) ->
Nurse/MA Assessment (Confirm chief complaints, review allergies/medications , brief
past medical history)
✔✔CLINIC FLOW - PHYSICIAN EVAL - ✔✔Review the patient's medical records
(Assessment & plan from the previous visit, Labs and/or imaging results) -> History and
Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical
Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the
symptoms)
✔✔CLINIC FLOW - ORDERS & RESULTS - ✔✔Orders (Laboratory studies, Imaging
studies, and Procedures) -> Results (May result during visit (rare) or in a few days)
✔✔CLINIC FLOW - ASSESSMENT & PLAN - ✔✔Assessment (The list of diagnoses) ->
Plan (Follow-up with specialist if necessary, Instructions for lifestyle and preventative
care, and Follow-up for next routine appointment)
✔✔CLINIC FLOW - CHECK-OUT - ✔✔Check-out (Home vs. sent to the ED, Patient
education provided, and Patient will often stop at the front desk on the way out to
schedule next appointment)
✔✔SECTIONS OF A CHART - ✔✔S (Subjective), O (Objective), A (assessment), and P
(Plan)
✔✔Past diagnosis or surgery - ✔✔Past History
✔✔Physician's observation - ✔✔Physical Exam
✔✔High blood pressure - ✔✔Hypertension (HTN)
✔✔High cholesterol - ✔✔Hyperlipidemia (HLD)
, ✔✔Thyroid problem - ✔✔Usually Hypothyroidism, sometimes Hyperthyroidism
✔✔Diabetes - ✔✔Diabetes Mellitus (DM)
✔✔"I only take pills for my diabetes" - ✔✔Non-Insulin Dependent Diabetes Mellitus
(NIDDM)
✔✔"I take shots (insulin) for my diabetes" - ✔✔Insulin Dependent Diabetes Mellitus
(IDDM)
✔✔Heart disease - ✔✔Usually Coronary Artery Disease (CAD)
✔✔Heart attack - ✔✔Myocardial Infarction (MI) and CAD
✔✔Heart failure - ✔✔Congestive Heart Failure (CHF)
✔✔Irregular heartbeat - ✔✔Arrhythmia
✔✔Murmur - ✔✔Heart murmur
✔✔Episodes of abnormally fast/racing heartbeat - ✔✔Supraventricular Tachycardia
(SVT)
✔✔Emphysema/Chronic Bronchitis - ✔✔Chronic Obstructive Pulmonary Disease
(COPD)
✔✔Blood clot in lung - ✔✔Pulmonary Embolism (PE)
✔✔Pneumonia - ✔✔Pneumonia (PNA)
✔✔Reflux - ✔✔Gastroesophageal Reflux Disease (GERD)
✔✔Ulcer - ✔✔Gastric Ulcer or Peptic Ulcer Disease (PUD)
✔✔Hepatitis - ✔✔Hepatitis A, Hepatitis B, or Hepatitis C
✔✔Crohn's/UC - ✔✔Crohn's Disease or Ulcerative Colitis
✔✔Irritable bowel - ✔✔Irritable Bowel Syndrome (IBS)
✔✔Bladder infection - ✔✔Urinary Tract Infection (UTI)
✔✔Kidney infection - ✔✔Pyelonephritis (Pyelo)
