Medical Scribe Training

Record patient's symptoms and medical history = Seeing patients with the clinician Document the assessment and plan = Dictated by the clinician Look up old medical records = Miscellaneous tasks Perform the physical examination = Done by the clinician

Gain first-hand experience in medicine = Direct exposure to medicine Observe a variety of patients = Gain knowledge of medical terminology Learn clinician decision making = One-of-a-kind experience Become versed in medical terminology = Learn from clinicians

Prepare laptop and familiarize with patients = Before the clinician arrives See patients with the clinician = When the clinician arrives Document the assessment and plan = After the physical exam Get the patient ready for check-out = After the clinician's orders

<p>Asks the patient questions = During the physical examination Verbalizes the findings to the scribe = After the physical examination Performs the physical examination = Before dictating the assessment and plan Informs the scribe of orders = After the physical examination</p> Signup and view all the answers

<p>Lessen the clinician's burden of documentation = Improve the clinician's efficiency Function as the clinician's personal assistant = Gain first-hand experience in medicine Record the patient's symptoms and medical history = Learn clinician decision making Work one-on-one with a clinician = Gain knowledge of medical terminology</p> Signup and view all the answers

<p>Recording the patient's symptoms and medical history = Done with the clinician Looking up old medical records = Miscellaneous task Documenting the assessment and plan = Done after the physical exam Transcribing instructions from the physician = Done with the clinician's orders</p> Signup and view all the answers

<p>Fast-paced = Always new work to be done Bustling = Filled with miscellaneous tasks Intense = Filled with direct exposure to medicine Rewarding = Filled with excitement</p> Signup and view all the answers

<p>Chronic = Long-standing, constant Acute on Chronic = New exacerbation of a chronic condition Resolved = Gone, no longer existing Transient = Resolving spontaneously after onset</p> Signup and view all the answers

<p>Gain first-hand experience in medicine = Become versed in medical terminology Observe a variety of patients = Learn clinician decision making Learn clinician decision making = Gain knowledge of medical terminology Become versed in medical terminology = Gain first-hand experience in medicine</p> Signup and view all the answers

<p>Intermittent = Symptoms that completely resolve at times, but continue to return repeatedly Paroxysmal = Occasional, sporadic, transient Fluctuating = Symptoms that are always present but changing in severity, never fully resolving Acute = Opposite of chronic</p> Signup and view all the answers

<p>Family History (FHx) = A part of the medical chart that lists diseases and health conditions in your family Health Insurance Portability and Accountability Act (HIPAA) = Federal law that provides national standards to protect sensitive patient health information History of present illness (HPI) = A part of the medical chart describing the development of the illness Review of system (ROS) = A part of the medical chart that is a checklist of the symptoms the patient has or does not have</p> Signup and view all the answers

<p>r/o = Rule Out (e.g.X-ray of the wrist to r/o fracture) s/p = Status Post (after) example: Headache s/p fall pt = Patient SHx = Social History (addressing substance use, occupation, diet exercise, living situation, etc.)</p> Signup and view all the answers

<p>Acute = Opposite of chronic Chronic = Long-standing, constant Paroxysmal = Occasional, sporadic, transient Intermittent = Symptoms that completely resolve at times, but continue to return repeatedly</p> Signup and view all the answers

<p>Review of system (ROS) = A part of the medical chart that is a checklist of the symptoms the patient has or does not have History of present illness (HPI) = A part of the medical chart describing the development of the illness Social History (SHx) = A part of the chart addresses substance use, occupation, diet exercise, living situation, etc. Family History (FHx) = A part of the medical chart that lists diseases and health conditions in your family</p> Signup and view all the answers

<p>Fluctuating = Symptoms that are always present but changing in severity, never fully resolving Paroxysmal = Occasional, sporadic, transient Transient = Resolving spontaneously after onset Resolved = Gone, no longer existing</p> Signup and view all the answers

<p>HIPAA = Federal law that provides national standards to protect sensitive patient health information FHx = Family History (lists diseases and health conditions in your family) pt = Patient HPI = History of present illness (describing the development of the illness)</p> Signup and view all the answers

<p>Anatomical Position = To stand erect with arms at the sides and palms of the hands turned forward Anterior = Situated in front of or directed toward the front Inferior = Lower on the body, farther from the head Posterior or Dorsal = Rear or back</p> Signup and view all the answers

<p>C-spine = Cervical spine (C1-C7) L-spine = Lumbar spine (L1-L5) T-spine = Thoracic spine (T1-T12) Fontanel = Anatomical feature of an infant’s skull, the “soft-spot”</p> Signup and view all the answers

<p>Distal = Farther from the trunk of the body Medial = Nearer to the midline Palmar or Volar = Palm side of hand or body Plantar = Sole of foot</p> Signup and view all the answers

<p>Left Lower Quadrant (LLQ) = Left Lower Quadrant Of the abdomen Left Upper Quadrant (LUQ) = Left Upper Quadrant of the abdomen Right Lower Quadrant (RLQ) = Right Lower Quadrant of the abdomen Right Upper Quadrant (RUQ) = Right Upper Quadrant of the abdomen</p> Signup and view all the answers

<p>Prone = Body position lying face down with forearms and hands turned palm side down Supine = Body position lying face up Superficial = Nearer to the surface Suprapubic = Lower central region on the abdomen</p> Signup and view all the answers

<p>Epigastric = Upper central region of the abdomen Inferior = Lower on the body, farther from the head Lateral = Farther from the midline Superior = Higher on the body, nearer to the head</p> Signup and view all the answers

<p>Acute = New onset, likely concerning Diffuse = Generalized; not localized to any specific location Proximal = Nearer to the trunk of the body Left Lower Extremity (LLE) = Left leg</p> Signup and view all the answers

<p>Right Upper Extremity (RUE) = Right arm Right Lower Extremity (RLE) = Right leg Left Upper Extremity (LUE) = Left arm Fontanel = Anatomical feature of an infant’s skull, the “soft-spot”</p> Signup and view all the answers

<p>Arthritis = Inflammation of the joints Cellulitis = Infection of skin cells Cirrhosis = Inflammation of the liver Cholelithiasis = Production of gallstones</p> Signup and view all the answers

<p>Atrial fibrillation = Irregular and often very rapid heart rhythm Bell’s Palsy = Localized facial nerve dysfunction Bronchitis = Inflammation/Infection of the bronchi Cancer = Carcinoma</p> Signup and view all the answers

<p>Cholecystitis = Inflammation of the gallbladder Chronic renal failure = Decrease in the kidneys' ability to filter waste Cerebrovascular accident = Blood supply to the brain is restricted or absent Congestive heart failure = Serious condition in which the heart doesn't pump blood efficiently</p> Signup and view all the answers

<p>Conjunctivitis = Infection of the outer layer of the eye Coronary artery disease = Buildup of plaque in the arteries that supply oxygen-rich blood Costochondritis = Inflammation of the rib cartilage Croup = Viral infection of the upper airway</p> Signup and view all the answers

<p>Deep venous thrombosis = Blood clot forms in a vein located deep inside the body Dermatitis = Inflammation of the skin Diverticulitis = Acute inflammation of the diverticula pouches Ectopic pregnancy = Egg developing outside the uterus</p> Signup and view all the answers

<p>Endometriosis = Presence of functioning endometrial tissue outside of the uterus Gastroenteritis = General term for inflammation of the GI tract Gastroesophageal reflux disease = Digestive disorder that occurs when acidic stomach juices back up Gout = Type of arthritis</p> Signup and view all the answers

<p>Hepatitis = Inflammation of the liver Hyperglycemia = High blood sugar due to diabetes Hyperlipidemia = High cholesterol Hypertension = High blood pressure</p> Signup and view all the answers

<p>Commitment = Consistency in working a minimum of two shifts per week Reliability = Ability to work with a clinician during their full shift Critical thinking = Analyzing medical information accurately Excellent communication skills = Interacting with clinicians effectively</p> Signup and view all the answers

<p>Extensive medical knowledge = Gain valuable experience in the field of medicine Personal experience = Develop a strong understanding of medical practices Invaluable letters-of-reference = Enhance career opportunities First-hand exposure to the field of medicine = Increase confidence in medical settings</p> Signup and view all the answers

<p>Hypoglycemia = Low blood-sugar Hypotension = Low blood pressure Stroke = Blood supply to the brain is restricted or absent UTD = Up to Date</p> Signup and view all the answers

<p>Excellent computer skills = Efficiently using software for medical documentation Typing speed of 50 wpm = Quickly recording medical information Organization = Managing time effectively during shifts Diligent attentiveness = Maintaining focus during long clinical shifts</p> Signup and view all the answers

<p>Appendicitis = Dangerous infection of the appendix Abscess = Collection of pus beneath the skin Arthritis = Inflammation of the joints Cirrhosis = Inflammation of an organ</p> Signup and view all the answers

<p>Scribing = A strenuous and demanding job Training regime = Rigorous and demanding Work environment = Stressful at times Job outcome = Lucrative and fulfilling</p> Signup and view all the answers

<p>COPD = Chronic inflammatory lung disease CVA = Blood supply to the brain is restricted or absent GERD = Digestive disorder that occurs when acidic stomach juices back up WNL = Within Normal Limits</p> Signup and view all the answers

<p>Clinician's shift = A scribe during their full shift Training schedule = Consistency in working a minimum of two shifts per week Scribe's availability = Providing accurate times to work with clinicians Job commitment = Dedicating 1-2 years to working as a scribe</p> Signup and view all the answers

<p>Motivation = Becoming a successful scribe Capability = Achieving benefits in the medical field Commitment = Participating in a rigorous training regime Professionalism = Demonstrating maturity in the workplace</p> Signup and view all the answers

<p>Scribing = A unique and demanding job Job requirements = Not like volunteer work Work environment = Genuinely difficult and stressful at times Job outcome = Not easily achieved</p> Signup and view all the answers

<p>Scribing = Fun and exciting Job requirements = Necessitating a strong work ethic Work environment = Providing direct exposure to medicine Job outcome = Increasing confidence in medical settings</p> Signup and view all the answers