VCRT Final Exam Study Guide (Updated fall 2022) A+
guarantee in your Exam, (Answered)
Subjective vs. objective - Feeling vs. fact
Pain vs. tenderness - Patient's feeling vs. physician's assessment
Benign - Normal, no
...
VCRT Final Exam Study Guide (Updated fall 2022) A+
guarantee in your Exam, (Answered)
Subjective vs. objective - Feeling vs. fact
Pain vs. tenderness - Patient's feeling vs. physician's assessment
Benign - Normal, nothing of concern
Acute vs. chronic - New onset vs. long standing
Baseline - An individual's normal state of being
Auscultation - Listening with a stethoscope
Palpation - The act of pressing on an area (by the physician)
Inpatient - Admitted to the hospital overnight
Outpatient - Seen and sent home the same day
Chief complaint - The main reason for the patient's visit
Meaningful use - A set of government mandated criteria that must be obtained for every
patient
Medical decision making - The physician's thought process
Mid-level providers - Nurse Practitioner (LNP) or Physician's Assistant (PA) that works
under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - Records medical histories and symptoms, monitors the
patient, completes meaningful use requirements, administers medications, assists with
procedures
Scribe - Documents the patient's visit on behalf of the physician; an unlicensed person
performing documentation and other non-clinical tasks under the direction of a
healthcare provider
New patient - No previous records, longer visit, detailed chart
Established patient - Previous records available, shorter visit, concise chart
Diagnostic visit - New problem, chief complaint = new symptom, goal is to determine
cause of the problem and appropriate treatmentHealth maintenance visit - Check-up, chief complaint = management of a chronic
problem, goal is to assess progress of ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? - Established
A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - Diagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be? - Health maintenance
Clinic flow - Check-in -> physician evaluation -> orders & results -> assessment & plan -
> check-out
Who obtains meaningful use information? - Nurse/MA
Meaningful use information - Chief complaint, vital signs (HR, temp., BP, RR), height,
weight, BMI, smoking status
Differential diagnosis - DDx; ONLY for a diagnostic visit; possible Dx that may be
causing symptoms
Who is the first person to speak with the patient after s/he is placed in a room? -
Nurse/MA
What doe H&P abbreviate and who performs this evaluation? - History & physical; the
physician
Is a differential diagnosis necessary for a health maintenance visit? - No; only for a
diagnostic visit
What information will be included in the patient's plan? Give 3 examples. - Follow-up
with specialist if necessary, instructions for lifestyle and preventative care, follow-up for
next routine appointment
HPI or ROS contains... - Patient complaint
Past history contains... - Past diagnosis or surgery
Physical exam contains... - Physician's observation
Results contains... - Study
Assessment contains... - Current diagnosis
[Show More]
