SCRIBEAMERICA OUTPATIENT EVALUATION EXAM
ACTUAL QUESTIONS AND ANSWERS SURE A+
✔✔-itis - ✔✔inflammation/infection
✔✔-osis - ✔✔Disease
✔✔-ectomy - ✔✔Surgical removal
✔✔-lithiasis - ✔✔Stones
✔✔Nephr- - ✔✔Kidney/renal
✔✔Chole- - ✔✔Gallbladder
✔✔Mast- - ✔✔Breast
✔✔Hepa- - ✔✔Liver
✔✔PMHx - ✔✔Personal medical history
✔✔PSHx - ✔✔Past surgical history
✔✔SHx - ✔✔Social History
✔✔FHx - ✔✔Family history
✔✔Comorbidity - ✔✔Complex history of two or more chronic diseases simultaneously
✔✔ Subjective vs. objective: - ✔✔Feeling vs. fact
✔✔Pain vs. tenderness - ✔✔Patient's feeling vs. physician's assessment
✔✔Benign - ✔✔Normal, nothing of concern
✔✔Acute - ✔✔New onset, likely concerning
✔✔Chronic - ✔✔Long-standing, not of direct concern
✔✔Baseline - ✔✔An individual's normal state of being
✔✔Auscultation - ✔✔Listening with a stethoscope
, ✔✔Palpation - ✔✔The act of pressing on an area (by the physician)
✔✔Inpatient - ✔✔Admitted to the hospital overnight
✔✔Outpatient - ✔✔Seen and sent home the same day
✔✔Chief complaint - ✔✔The main reason for the patient's visit
✔✔Mid-Level Provider - ✔✔Nurse Practitioner (LNP) or Physician Assistant (PA) that
works under the supervision of a physician to diagnose and treat patients
✔✔Medical provider - ✔✔Mid-level provider that diagnoses and treats patients
✔✔Nurse or Medical Assistant - ✔✔Records medical histories and symptoms, monitors
the patient, completes the meaningful use requirements, administers medications,
assists with procedures
✔✔Clinical provider - ✔✔Includes both the mid-level provider and nurse or medical
assistant that are direct patient care
✔✔Scribe - ✔✔Documents the patient's visit on behalf of the physician
✔✔Clerical - ✔✔Receptionist and scribe that there is no patient care and only
documentation
✔✔Scribes CAN.... - ✔✔-Document the history, physical exam, results, procedures,
assessment, and plan
-Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
✔✔Assessment vs Plan - ✔✔Diagnosis vs Treatment
✔✔Scribes CANNOT... - ✔✔-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
-NO direct patient care, No patient samples, No using logins other than your own
✔✔NEW Patient - ✔✔No previous records, Longer visit, and Detailed chart
ACTUAL QUESTIONS AND ANSWERS SURE A+
✔✔-itis - ✔✔inflammation/infection
✔✔-osis - ✔✔Disease
✔✔-ectomy - ✔✔Surgical removal
✔✔-lithiasis - ✔✔Stones
✔✔Nephr- - ✔✔Kidney/renal
✔✔Chole- - ✔✔Gallbladder
✔✔Mast- - ✔✔Breast
✔✔Hepa- - ✔✔Liver
✔✔PMHx - ✔✔Personal medical history
✔✔PSHx - ✔✔Past surgical history
✔✔SHx - ✔✔Social History
✔✔FHx - ✔✔Family history
✔✔Comorbidity - ✔✔Complex history of two or more chronic diseases simultaneously
✔✔ Subjective vs. objective: - ✔✔Feeling vs. fact
✔✔Pain vs. tenderness - ✔✔Patient's feeling vs. physician's assessment
✔✔Benign - ✔✔Normal, nothing of concern
✔✔Acute - ✔✔New onset, likely concerning
✔✔Chronic - ✔✔Long-standing, not of direct concern
✔✔Baseline - ✔✔An individual's normal state of being
✔✔Auscultation - ✔✔Listening with a stethoscope
, ✔✔Palpation - ✔✔The act of pressing on an area (by the physician)
✔✔Inpatient - ✔✔Admitted to the hospital overnight
✔✔Outpatient - ✔✔Seen and sent home the same day
✔✔Chief complaint - ✔✔The main reason for the patient's visit
✔✔Mid-Level Provider - ✔✔Nurse Practitioner (LNP) or Physician Assistant (PA) that
works under the supervision of a physician to diagnose and treat patients
✔✔Medical provider - ✔✔Mid-level provider that diagnoses and treats patients
✔✔Nurse or Medical Assistant - ✔✔Records medical histories and symptoms, monitors
the patient, completes the meaningful use requirements, administers medications,
assists with procedures
✔✔Clinical provider - ✔✔Includes both the mid-level provider and nurse or medical
assistant that are direct patient care
✔✔Scribe - ✔✔Documents the patient's visit on behalf of the physician
✔✔Clerical - ✔✔Receptionist and scribe that there is no patient care and only
documentation
✔✔Scribes CAN.... - ✔✔-Document the history, physical exam, results, procedures,
assessment, and plan
-Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
✔✔Assessment vs Plan - ✔✔Diagnosis vs Treatment
✔✔Scribes CANNOT... - ✔✔-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
-NO direct patient care, No patient samples, No using logins other than your own
✔✔NEW Patient - ✔✔No previous records, Longer visit, and Detailed chart
