CITYMD MEDICAL SCRIBE PRACTICAL
EXAM QUESTIONS AND ANSWERS
PAST medical history - Answer-"now im going to ask you about your past medical
history"
**first ask about current medications**
ask "are you taking any prescribed medications" at least twice
--if you dont know the name, google it
------- search in green (Rx only selected)
---click on medication
---once you have full list, click verified box
*if they dont know the name of it*
-----they can call pharmacy, ask what its for, they can call someone at home, select
unknown medication, but add what it is for and tell provider
step two:
click past medical history
--what is "X" medication for?
--"Aside from these, are there any other medication conditions we should know about?"
--click the ... and type in find box, then click history verified when done
step three:
allergies
"do you have any allergies to medication
-click browse Rx... add medication ---> allergies verified
Pencillin ---> penvk
Only use the add button if you are adding iv dye or ct dye
step 4:
surgeries - document all surgeries
--click on ... -> type in search box
indicate laterallity
click verify
Step 5:
family history
specifically biological mother and father
only diabetes and hypertension
--if no, click ... and then denies whatever it is
click verify family history
Step 6:
social history
specifically ask about tobacco
, --click details in substances, then click value drop
click which ever where is applicable
----if they smoke, provide counseling yes and date ... dont have to ask details
if they are under 16, ask household tobacco
if BMI or BP are in red, then you add more info here
--- normal BMI 18.5-25.0
---bp pre-hypertension: 120-139/80-89
---BP hypertension: 140/90
click verified
Step 5 of first half of the chart - Answer-HPI in subjective
-click body system related to body system
secondary window pops up
1. onset, severity, nature - first
2. pertaint positive (BOLD)
3. free info
4. pertaint negatives
doesnt currently have a fever or in distress
-->document "mild"
Nature 3 months or less is ACUTE
+/- related to that body system
step 6 of first half of chart ----> ROS - Answer-one symptoms per body system
--avoid asking about chest pain, shortness of breathe, and palpitations (red flag
systems)
"now im going to ask a few questions about what may or may not have to do with what
your here for today, but they will help the provider better assist you"
New patients --> 10 systems
Old --> 3 systems
complicated, old ---> 10 systems
click through, some stuff you'll already know based on the chief/hpi
first half of the chart after step 6 - Answer-STOP
excuse self from room
say you are going to talk to the dr.
lock the computer and sanitize hands
Talking to the dr after first half of the chart - Answer-age, gender, onset, what chief
complaint is, +/- and what they have taken if anything
EXAM QUESTIONS AND ANSWERS
PAST medical history - Answer-"now im going to ask you about your past medical
history"
**first ask about current medications**
ask "are you taking any prescribed medications" at least twice
--if you dont know the name, google it
------- search in green (Rx only selected)
---click on medication
---once you have full list, click verified box
*if they dont know the name of it*
-----they can call pharmacy, ask what its for, they can call someone at home, select
unknown medication, but add what it is for and tell provider
step two:
click past medical history
--what is "X" medication for?
--"Aside from these, are there any other medication conditions we should know about?"
--click the ... and type in find box, then click history verified when done
step three:
allergies
"do you have any allergies to medication
-click browse Rx... add medication ---> allergies verified
Pencillin ---> penvk
Only use the add button if you are adding iv dye or ct dye
step 4:
surgeries - document all surgeries
--click on ... -> type in search box
indicate laterallity
click verify
Step 5:
family history
specifically biological mother and father
only diabetes and hypertension
--if no, click ... and then denies whatever it is
click verify family history
Step 6:
social history
specifically ask about tobacco
, --click details in substances, then click value drop
click which ever where is applicable
----if they smoke, provide counseling yes and date ... dont have to ask details
if they are under 16, ask household tobacco
if BMI or BP are in red, then you add more info here
--- normal BMI 18.5-25.0
---bp pre-hypertension: 120-139/80-89
---BP hypertension: 140/90
click verified
Step 5 of first half of the chart - Answer-HPI in subjective
-click body system related to body system
secondary window pops up
1. onset, severity, nature - first
2. pertaint positive (BOLD)
3. free info
4. pertaint negatives
doesnt currently have a fever or in distress
-->document "mild"
Nature 3 months or less is ACUTE
+/- related to that body system
step 6 of first half of chart ----> ROS - Answer-one symptoms per body system
--avoid asking about chest pain, shortness of breathe, and palpitations (red flag
systems)
"now im going to ask a few questions about what may or may not have to do with what
your here for today, but they will help the provider better assist you"
New patients --> 10 systems
Old --> 3 systems
complicated, old ---> 10 systems
click through, some stuff you'll already know based on the chief/hpi
first half of the chart after step 6 - Answer-STOP
excuse self from room
say you are going to talk to the dr.
lock the computer and sanitize hands
Talking to the dr after first half of the chart - Answer-age, gender, onset, what chief
complaint is, +/- and what they have taken if anything
