Scribe Final Exam Elaborations with Complete Solution

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Scribe Final Exam Elaborations with Complete Solution 1 / 15 1. 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) 2. 7 Parts of the HPI: 1. Context 2. Time/Duration; time = course of symptoms (improving, worsening, constant, intermittent, etc.); duration = total time symptoms have been present 3. Location 4. Quality 5. Severity 6. Modifying Factors 7. Pertinent positive and negatives 3. Level 5 Chart: HPI: 4-7 ROS: 10+ PFSH: 2+ PEx: 8+ systems 4. Supination: Turning the hand so that the palm faces upward. 5. Volar: Pertaining to the palm of the hand or the sole of the foot. 6. Inferior: Situated below or further away from the head. 7. Midline: Line that divides the body into right and left halves. 8. Abduction: Moving away from the midline. 9. ACLS: Advanced cardiac life support. 10. AMA: Against medical advice. 11. DNR: do not resuscitate 12. DOA: Dead on arrival 13. OSH: Outside hospital 14. PCP: Primary care physician 15. PTA: Prior to arrival 16. UTD: Up to date (as in immunizations) 17. WNL: within normal limits 18. yo: year old 19. B/L: bilateral [Show More]

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