Course 1: Welcome and Patient Health History

Established Patient

-A patient that has been seen at the clinic within the last 3 years -previous records available -shorter visit -concise chart

New Patient

-A patient that has never been seen at the clinic, or was seen greater than 3 years ago - no previous records -longer visit -detailed chart

Health Management

-Check-up -CC: routine physical or management of chronic problems -goals is preventative care and/or assessing progress of ongoing medical problems

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

Diagnostic

-New problem -CC: new symptom -goal is to determine cause of problem and appropriate treatment

why is age important in family history

-a younger age of onset (under 55) means higher genetic risk -older age of onset is likely more due to environment than genetics

Scribes cannot...

-touch patients -write orders or prescriptions -give verbal orders -sign or authenticate any chart or record -handle bodily fluids or specimens

leg amputated

Above Knee Amputation (AKA) Below Knee Amputation (BKA)

"balloon in my heart"

Angioplasty --> PMHx CAD

Current diagnoses is where in medical chart

Assessment

Chief Complaint

CC; the main reason for the patient's visit

Clinic Flow

Check in, History, Physical exam, Orders/results, Assessment/plan, Check out

emphysema or chronic bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

heart failure

Congestive Heart Failure (CHF)

heart bypass

Coronary Artery Bypass Graft (CABG) --> PMHx CAD

Heart disease

Coronary Artery Disease (CAD)

"stents in my heart"

Coronary Stents --> PMHx CAD

What type of visits will have differential diagnoses (DDx) listed in the Assessment?

Diagnostic Visit

Tenderness

Doctor's finding of reproducible pain

EHR/EMR

Electronic health record and Electronic medical record.

Objective

Factual finding from the provider

Subjective

Feeling

reflux

Gastroesophageal Reflux Disease (GERD)

Patient Complaint is where in medical chart

HPI or ROS (Subjective)

high cholesterol

Hyperlipidemia (HLD)

"I take shots (insulin) for my diabetes"

Insulin Dependent Diabetes Mellitus (IDDM)

Chronic

Long-standing , not of direct concern

Acute

New onset, likely concerning

Past diagnoses/surgeries is where in medical chart

Past History (Subjective usually included in HPI/ROS)

PSHx

Past Surgical History

Pain

Patient's feeling of discomfort

Physician's observations is where in medical chart

Physical Exam (Objective Evaluation)

Treatment plan is where in medical chart

Plan

Labs, Imaging, Studies is where in medical chart

Results (Objective Evaluation)

SHx

Social History->Tobacco use, alcohol use, illicit drug use, occupation, living circumstances

adenoids removed

adenoidectomy

"bluge in my aorta"

aortic aneurysm

appendix removed

appendectomy

irregular heartbeat

arrhythmia

joint repair

arthroplasty

enlarged prostate

benign prostatic hyperplasia (BPH)

cancer

cancer or carcinoma (CA)

"neck arteries cleaned"

carotid endarterectomy

stroke

cerebrovascular accident (CVA)

chemo

chemotherapy

gallbladder removed

cholecystectomy

"i'm on dialysis"

chronic kidney disease (CKD) on dialysis

blood clot in my leg

deep vein thrombosis (DVT)

diabetes

diabetes mellitus (DM)

FHx

family history

ulcers

gastric ulcer or peptic ulcer disease (PUD)

brain bleed

hemorrhagic CVA

high blood pressure

hypertension (HTN)

uterus removed

hysterectomy

it's gone

in remission

irritable bowel

irritable bowel syndrome (IBS)

"blood clot in brain"

ischemic CVA

breast removal

mastectomy

heart attack

myocardial infarction(MI) and CAD

kidney removed

nephrectomy

"I only take pills for my diabetes"

non-insulin dependent diabetes mellitus (NIDDM)

ovary removed

oophorectomy

part of my colon removed

partial colectomy

part of my lung removed

partial lobectomy

PMHx

past medical history

"bad blood flow in my legs"

peripheral vascular disease (PVD)

pneumonia or lung infection

pneumonia (PNA)

blood clot in lung

pulmonary embolism (PE)

kidney infection

pyelonephritis

radiation

radiation therapy

true allergy

rash, itching, swelling, or difficulty breathing. otherwise it is "adverse reaction"

spleen removed

splenectomy

they cut it out

status-post surgical resection

S.O.A.P.

subjective, objective, assessment, plan

tonsils removed

tonsillectomy

"mini stroke"

transient ischemic attack (TIA)

bladder infection

urinary tract infection (UTI)

spread to my...

with metastasis to the...