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...
