VCRT Final Exam Study Guide (Updated fall 2022) A+ guarantee in your Exam, (Answered)

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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]

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