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28 Cards in this Set
- Front
- Back
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Subjective vs objective |
Feeling vs fact |
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Pain vs tenderness |
Patient's feeling vs. physician's assessment |
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Benign |
Normal, of no concern |
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Acute vs. chronic |
New onset vs. long standing |
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Baseline |
An individual's normal state of being |
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Auscultation |
Listening with stethescope |
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Palpation |
Act of pressing on an area |
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Inpatient |
Admitted to the hospital overnight |
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Outpatient |
Seen and sent home same day |
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Chief complaint |
Main reason for patient's visit |
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Meaningful Use |
A set of government mandated criteria that must be obtained for every patient |
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Medical Decision Making |
The physician's thought process |
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People in Clinic |
People in Clinic |
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Mid-Level Provider |
Licensed Nurse Practioner, Physician Assistant works under supervision of physician |
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Nurse or Medical Assistant |
Records medical histories, symptoms, monitors patient, COMPLETES MEANINGFUL USE |
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Receptionist |
Answers phone calls, schedules appointments |
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Scribe |
Documents patient's visit on behalf of physician |
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Scribes CAN |
Document history, exam, results, etc. Access/document lab results/findings Locate and obtain PMHx, etc. Record physician interpretations |
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Scribes CANNOT |
Partake in activity affecting patient health Touch patients Touch bodily fluids or specimens Sign off anything Give verbal orders |
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New vs. Established patients |
New - no prev. records, longer visit, detailed chart Established - prev. records, shorter visit, cursory chart |
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Diagnostic vs. Health Maintenance Visits |
New problem, new symptom vs. check-up, management |
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Clinic Flow |
1. Check-in 2. Physician evaluation 3. Orders and results 4. Assessment and plan 5. Check-out |
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Check-in |
1. |
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Physical Evaluation |
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Orders and Results |
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Assessment and Plan |
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Check-out |
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Documentation System |
All Meds |
