The patient’s medical history, diagnostic results, treatments, as well as identifying information is stored in the

The provider asks the patient if she has experienced any nausea, and the patient replies “no.” Which speaking verb is appropriate for reviewing symptomology like this?

In the HPI, what are nasal/sinus congestion, sinus pressure, rhinorrhea, and postnasal drainage?

Which phrase indicates the duration of the patient’s illness?

Which is not a portion of the history and physical (H&P)?

__________________________ are blank documents that are preconfigured to show an outline of a standard patient encounter, populated with generic data waiting to be modified to match the current visit.

Which statement is a chief complaint?

Pertinent positives are those problems which the patient ________________ having and which are related to the chief complaint.

The patient states that her pain is a 5 on a scale of 1 to 10. Into which descriptor is this information placed?

The patient states that he cannot hear with his left ear. Into which descriptor is this information placed?

The patient states that she has been vomiting for the past three days. Into which descriptor is this information placed?

The patient states that the pain begins below his shoulder blade and extends up his neck to the area behind his left ear. Into which descriptor is this information placed?

Which is a description of the character or quality of the symptom?

In the review of systems (ROS), a problem related to the fingernails would be placed in which body system?

A Medical Scribe responsibilities would include the following except

When new patient arrives at the medical office, they are asked for patient demographic information Which form do you need to obtain these information?

The provider describes the patient as having a toxic appearance, meaning what?

The patient relates a sensation of “pins and needles” in her legs. How does the scribe record this symptom in the review of systems?

Besides gastrointestinal, into which other body system might the scribe place the patient’s symptom of fecal incontinence in the review of systems?

Romberg’s sign tests the patients _______________________, or awareness of body position.

The patient’s history elicits that he suffered a stroke two years ago. The scribe might list this as ______________________________ in the patient’s medical history.

An antianxiety drug is also known as a(n)

A patient with a temperature of 101.6 °F would be described as

Which term also means dorsal?

Pertinent positives are those problems which the patient ________________ having and which are related to the chief complaint.

According to E/M guidelines, how many HPI documentation elements are required in a record for a high complexity or extended emergency department visit?

In the review of systems (ROS), a problem related to the fingernails would be placed in which body system?

What type of imaging visualizes arteries and other vessels using a contrast medium?

If a Medical Scribe did not understand, or did not hear, a part of the patient’s history or physical exam, the scribe should

A patient is asking the scribe a question about her treatment plan. What should the medical scribe do?

A patient mentioned that he has chronic allergic rhinitis. Which part of the chart does this belong?

Abnormal sound due to turbulent arterial flow (due to partial obstruction or lozalized high velocity blood flow)

Doctor Sam asked the patient to describe how his heart problem began, his symptoms from Day 1 and how it is today. Where do you put this in the chart?

Patient findings showed slow heart rate (below 60 bpm). What is most likely to be seen in the diagnosis?

What is CAD?

The condition of the skin and nails looking a purplish blue colour due to lowered oxygen level in the blood.

"Patient presents with chest pain. Patient first began experiencing symptoms approximately 3 day(s) ago. It is located in the left chest. This usually ocurrs after walking up the steps. It is radiating to the left shoulder." What part of patient chart is this from?

Patient mentioned that his doctor ordered stress test last week. What does this mean?

Prefix meaning smaller or less than usual.

"Watch caffeine, alcohol, decongstants. Light exercise like walking is ok." This is in which part of the chart?

This is a tube placed inside a coronary artery to keep it open.

Insufficient blood flow to tissue due to blockage in the blood flow through the arteries.

Which among the following should be part of the Review List?

Doctor Sam instructed Patient X to take 1 tablet of Atenolol 25 mg Tablet twice a day. How do you fill this out this in the patient's chart?

Sedentary lifestyle - is most likely seen in which part of patient chart?

GENERAL: On examination AAO X 3 WNWD in NAD. In which part of medical chart is this from?

An assessment with J45 means?

A collection of fluid in an area such as the pericardium or the pleural cavity. Such a collection, if it is large, may lead to buildup of pressure on the heart or lungs, and often results in deterioration in their function, and so it may need to be drained.

Which among the following is an example of a needed trait for a Medical Scribe in Cardiology Practice?

A patient chart in a Cardiology practice should start with ___________?

Which among the following is NOT part of prescription refill creation writing?

Elevated heart rate (above 100 bpm)

Which among the following is attached to a chart that helps the doctor determine diagnosis and treatment plan?

In a patient chart who was seen by a cardiologist, what does AI mean?

In the event that the scribe will meet a patient for a routine visit prior to seeing the doctor, which among the following is th best thing to do?

A patient is in risk of Acute Coronary Syndrome. What is the best question to ask to patient for triage?

Which term means imbalance?

A patient who feels like the room is spining is experiencing ______?

The patient with a history of seizures since childhood reports that earlier today she was doing homework when she began to experience a sudden onset of a “hazy sensation” and saw a “burst of light.” She then awoke on the ground having apparently had a seizure with a loss of consciousness of unknown duration. The patient states that stress and lack of sleep are both seizure triggers, and she has had both with her upcoming finals week. What, if any, might the scribe list as a limitation to this history?

Since the patient is unable to complete the tandem walking test, the scribe can expect the physician to document what sign?