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[Show more]SOAP - Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) 
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) 
Assessment-Diagnosis (determined by combining subjective/objective info) 
Plan-Disposition (Admission, Discharge, Transfer instructions) 
7 Part...
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Add to cartSOAP - Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) 
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) 
Assessment-Diagnosis (determined by combining subjective/objective info) 
Plan-Disposition (Admission, Discharge, Transfer instructions) 
7 Part...
HPI - history of present illness 
ROS - Review of Systems 
PE - Physical Examination 
A/P - acssessment and planning 
CC - Chief Complaint 
Chief Complaint - statement or reason for the patient encounter 
History of present illness - detailed description of development of the patients present diseas...
Preview 3 out of 20 pages
Add to cartHPI - history of present illness 
ROS - Review of Systems 
PE - Physical Examination 
A/P - acssessment and planning 
CC - Chief Complaint 
Chief Complaint - statement or reason for the patient encounter 
History of present illness - detailed description of development of the patients present diseas...
Medical Decision Making (MDM) - The physician's thought process 
Pain vs. Tenderness - Patient's feeling vs. physician's assessment 
What does distress mean? - The doctor's judgment of discomfort 
Baseline - An individual's normal state of being 
What does Auscultation mean? - Listening with a ...
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Add to cartMedical Decision Making (MDM) - The physician's thought process 
Pain vs. Tenderness - Patient's feeling vs. physician's assessment 
What does distress mean? - The doctor's judgment of discomfort 
Baseline - An individual's normal state of being 
What does Auscultation mean? - Listening with a ...
What happens if you do not complete the course in 15 days and/or fail the final exam twice? - On 
the 15th day after passing the initial quiz, my course progress will be reset back to 0%. I will then be able 
to re-progress through the course. 
When does my certificate for passing Scribe101 expire? ...
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Add to cartWhat happens if you do not complete the course in 15 days and/or fail the final exam twice? - On 
the 15th day after passing the initial quiz, my course progress will be reset back to 0%. I will then be able 
to re-progress through the course. 
When does my certificate for passing Scribe101 expire? ...
Plantar - Sole side of foot 
Plantar flexion - Foot movement when toes flex down 
(pointing your toes) 
Supine - Body lying face up (chest up and back down) 
Afebrile - without fever 
diaphoresis - excessive sweating 
dysuria - painful urination 
emesis - vomiting 
epistaxis - bleeding from the nose...
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Add to cartPlantar - Sole side of foot 
Plantar flexion - Foot movement when toes flex down 
(pointing your toes) 
Supine - Body lying face up (chest up and back down) 
Afebrile - without fever 
diaphoresis - excessive sweating 
dysuria - painful urination 
emesis - vomiting 
epistaxis - bleeding from the nose...
Abduction - Movement of a body part away from the midline 
Adduction - Movement of a body part toward the midline 
Anatomical Position - The erect position of the body with arms at the side and palms of the hands 
facing forward. 
Anterior (Ventral) - Nearer to the front 
Bilateral - Paired structur...
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Add to cartAbduction - Movement of a body part away from the midline 
Adduction - Movement of a body part toward the midline 
Anatomical Position - The erect position of the body with arms at the side and palms of the hands 
facing forward. 
Anterior (Ventral) - Nearer to the front 
Bilateral - Paired structur...
A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks 
pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? - 
acute urinary tract infection in pregnancy, 2nd trimester 
A patient cut his left foot on a ...
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Add to cartA patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks 
pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? - 
acute urinary tract infection in pregnancy, 2nd trimester 
A patient cut his left foot on a ...
When is the best time to ask the provider to clarify things for the note? - When out of hearing 
range of patients and visitors. 
Which of the below is permitted per dress code in the clinical setting: - Scrubs 
The medical record is not used for: - Accreditation 
The following patient information i...
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Add to cartWhen is the best time to ask the provider to clarify things for the note? - When out of hearing 
range of patients and visitors. 
Which of the below is permitted per dress code in the clinical setting: - Scrubs 
The medical record is not used for: - Accreditation 
The following patient information i...
* What medical term describes the surgical removal of the gallbladder? - cholecystectomy 
What does "PHI" stand for? Expand the abbreviation. - Protected Health Information 
T/F. Sharing information about a case with family is allowed, as long as you are scribing with the 
physician assigned to th...
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Add to cart* What medical term describes the surgical removal of the gallbladder? - cholecystectomy 
What does "PHI" stand for? Expand the abbreviation. - Protected Health Information 
T/F. Sharing information about a case with family is allowed, as long as you are scribing with the 
physician assigned to th...
1x sold
Phase 1 - n 
y & vitals 
3.Past medical History 
4.Chief complaint 
5.HIP (history of present illness) 
6.ROS (review of systems) 
Rapid strep - Sore throat 
rapid flu - flu like symptoms 
Urine test - Urine complaints, abdominal complaints (if female) 
Visual acuity - eye complaints 
Past medical h...
Preview 2 out of 6 pages
Add to cartPhase 1 - n 
y & vitals 
3.Past medical History 
4.Chief complaint 
5.HIP (history of present illness) 
6.ROS (review of systems) 
Rapid strep - Sore throat 
rapid flu - flu like symptoms 
Urine test - Urine complaints, abdominal complaints (if female) 
Visual acuity - eye complaints 
Past medical h...
HTN CC - asymptomatic 
HLD CC - asymptomatic 
DM CC - polyuria, polydipsia 
CAD CC - CP or pressure 
Asthma CC - SOB, wheezing 
How do you diagnose HTN? - Check BP 
How do you diagnose HLD? - Check bloodwork 
How do you diagnose DM? - Fasting blood glucose, HA1C 
How do you diagnose HLD? - Check blo...
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Add to cartHTN CC - asymptomatic 
HLD CC - asymptomatic 
DM CC - polyuria, polydipsia 
CAD CC - CP or pressure 
Asthma CC - SOB, wheezing 
How do you diagnose HTN? - Check BP 
How do you diagnose HLD? - Check bloodwork 
How do you diagnose DM? - Fasting blood glucose, HA1C 
How do you diagnose HLD? - Check blo...
Hip osteoarthritis - Degenerative process of articular cartridge 
Rheumatoid arthritis - Autoimmune form of arthritis that results in joint deformity 
Paronychia - Infection of fingertips around fingernail 
Ganglion cyst - Fluid filled cyst that forms on top of a joint or tendon 
Boxers fracture - F...
Preview 2 out of 6 pages
Add to cartHip osteoarthritis - Degenerative process of articular cartridge 
Rheumatoid arthritis - Autoimmune form of arthritis that results in joint deformity 
Paronychia - Infection of fingertips around fingernail 
Ganglion cyst - Fluid filled cyst that forms on top of a joint or tendon 
Boxers fracture - F...
LOC - Level of consciousness 
MM - Mucous membrane 
CRT - capillary refil time 
CRI - Constant rate infusion 
IVC - Intravenous catheter 
COO - Change of orders 
TVI - total volume infused 
UOP - Urine output 
U - Urine 
BM - Bowel movement 
D+ - Diarrhea 
V+ - Vomiting 
Pk - PinkLP - Light Pink 
Ic...
Preview 2 out of 13 pages
Add to cartLOC - Level of consciousness 
MM - Mucous membrane 
CRT - capillary refil time 
CRI - Constant rate infusion 
IVC - Intravenous catheter 
COO - Change of orders 
TVI - total volume infused 
UOP - Urine output 
U - Urine 
BM - Bowel movement 
D+ - Diarrhea 
V+ - Vomiting 
Pk - PinkLP - Light Pink 
Ic...
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