Subjective
Objective
Vocab & abbreviations
Intro to Vituity, documentation, & HM
Doctor Scribe
100
What does SOAP stand for
Subjective, objective, assessment & plan
100
Which test has more exposure to radiation: an MRI or a CT?
A CT has 100x more exposure to radiation than an MRI.
100
A person with high blood pressure may have HTN, which stands for ___.
Hypertension
100
The patient asks for a glass of water. What do you do?
- tell the nurse, physician, etc.
- don't get him/her water without permission from physician
100
Alma is a 92 year old female who is 5'1" and weighs 88 pounds. What are two ways you could describe her in the physical exam section?
Thin, cachectic, emaciated, malnourished
200
List three things that can be documented in a patient's social history
Tobacco use, alcohol use, drug use, occupation, living circumstances.
200
List three labs on a CMP.
sodium, potassium, chloride, calcium, BUN, creatinine, GFR, total protein, total bilirubin, ALT, AST, & Glucose.
200
The patient isn't allowed to eat. The doctor orders for her to be NPO, which stands for ____
nothing per os (mouth)
200
List three things that are considered protected health information, that cannot be shared
Literally anything and everything! Never share: names, addresses, phone numbers, dates of birth/death/admission/discharge, identifying numbers, license plate numbers, photos, medical record numbers, social security numbers, email addresses
200
Tom is confesses that he drinks a 12-pack every day. You examine him and see that he is jaundiced and has scleral icterus. He likely has _____.
Cirrhosis/liver failure.
300
List two components of the first sentence of the HPI
name, age, gender, past medical history, chief complaint
300
A high ___ could indicate a PE, or pulmonary embolism
D-Dimer
300
NSAID stands for _____
Non-steroidal anti-inflammatory drug
300
What does HIPAA stand for
Health Insurance Portability and Accountability Act
300
Melanie is a 45 year old female who comes to the hospital complaining of weakness. She notes multiple episodes of hematochezia and melena. Her hemoglobin and hematocrit are both very low. If she is not a Jehovah's witness, she will likely feel better after a _____.
blood transfusion
400
A complete HPI contains several elements. The acronym OLDCART can help remember them. What does oldcart stand for?
Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing
400
This lab might lead to a CHF diagnosis.
BNP
400
______, or pain during palpation of the right upper quadrant, may indicate a gallbladder infection.
Murphy's sign
400
Name three of the four places a patient can be discharged to after leaving the hospital.
Home, SNF, Rehab, another hospital
400
A 72 year old female comes in with acute confusion, painful urination, and weakness. The doctor suspects that she has a UTI and orders a ____ to diagnose this.
Urine culture
500
Carla was admitted to the hospital on Friday for abdominal pain. On Saturday morning, the doctor was rounded on her patients and wrote progress notes. List two updates that Carla could give to be written in the progress note.
- pain worse or improved?
- tolerating food?
- how they slept
- updates from nurses
- other complaints
500
List two labs on a CBC
WBC, HGB, HCT, platelets
500
This patient was having trouble breathing and was placed on BiPAP, which stands for ___.
Bilevel positive airway pressure
500
What is the name of our scribe program manager(s)? Who is our medical director?
Program managers: Deanna & Darcy
Medical Director: Dr. McGowen
500
Samatha is an 86 year old who comes in with SOB, a productive cough, and wheezing. Her primary diagnosis is pneumonia. The doctor writes her assessment and plan and asks for your help. What two things could be part of her plan to treat pneumonia.
IS (incentive spirometer) to help her breath.
Sputum cultures
Antibiotics
Oxygen
(among others)