Scribe america op stuvia - Study guides, Class notes & Summaries

* What medical term describes the surgical removal of the gallbladder? - Answer cholecystectomy What does "PHI" stand for? Expand the abbreviation. - Answer 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 the case. - Answer False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Answer craniotomy A patien...

last day of the month - ANSWERget paid on what day for hours worked 10th-24th? 16th - ANSWERget paid on what day for hours worked 25th-9th? Sunday - ANSWERthe work week starts on what day of the week? subjective - ANSWERfeeling (from patient) objective - ANSWERfact (from provider) pain - ANSWERpatient's feeling, subjective tenderness - ANSWERphysician's observation, objective benign - ANSWERnormal, nothing of conern acute - ANSWERof new onset, less than 3 months chro...

abscess - ANSWERcollection of pus underneath the skin acute - ANSWERnew, usually rapid onset, opposite of chronic afebrile - ANSWERwithout a fever (less than 100.4) anterior - ANSWERlocated towards the front of body appendicitis - ANSWERinfection of the appendix auscultation - ANSWERlistening with a stethoscope benign - ANSWERnormal, not of concern catheter - ANSWERtube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage op...

scribes can - ANSWERdocument the SOAP scribes cannot - ANSWERpartake in any activity that may affect patient health or outcome; touch patients; handle bodily fluids or specimens; sign or authenticate any chart or record; give verbal orders or submit electronic orders new patient - ANSWERno previous records; longer visit; detailed chart established patient - ANSWERprevious records available; shorter visit; concise chart diagnostic clinic visit - ANSWERnew problem; cc: new symptom; goa...

last day of the month - ANSWERget paid on what day for hours worked 10th-24th? 16th - ANSWERget paid on what day for hours worked 25th-9th? Sunday - ANSWERthe work week starts on what day of the week? subjective - ANSWERfeeling (from patient) objective - ANSWERfact (from provider) pain - ANSWERpatient's feeling, subjective tenderness - ANSWERphysician's observation, objective benign - ANSWERnormal, nothing of conern acute - ANSWERof new onset, less than 3 months chro...

scribes can - ANSWERdocument the SOAP scribes cannot - ANSWERpartake in any activity that may affect patient health or outcome; touch patients; handle bodily fluids or specimens; sign or authenticate any chart or record; give verbal orders or submit electronic orders new patient - ANSWERno previous records; longer visit; detailed chart established patient - ANSWERprevious records available; shorter visit; concise chart diagnostic clinic visit - ANSWERnew problem; cc: new symptom; goa...

abscess - ANSWERcollection of pus underneath the skin acute - ANSWERnew, usually rapid onset, opposite of chronic afebrile - ANSWERwithout a fever (less than 100.4) anterior - ANSWERlocated towards the front of body appendicitis - ANSWERinfection of the appendix auscultation - ANSWERlistening with a stethoscope benign - ANSWERnormal, not of concern catheter - ANSWERtube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage op...