AST V3 Lecture 1 Assessment

Gastroenterology is the correct answer because this specialty focuses on the diagnosis and treatment of diseases and disorders of the digestive system, including the stomach and intestines. Abdominal pain and frequent episodes of vomiting are symptoms that are often associated with gastrointestinal issues such as gastritis, gastroenteritis, or peptic ulcers. Therefore, a patient experiencing these symptoms would be referred to a gastroenterologist for evaluation and appropriate treatment.

Dermatology is the correct answer because it is the healthcare specialty that focuses on the diagnosis and treatment of skin conditions. Severe acne is a common skin condition that can cause physical and emotional distress, and dermatologists are specifically trained to address and manage such conditions. They have expertise in prescribing appropriate medications, performing procedures like extractions or chemical peels, and providing guidance on skincare routines to help improve the patient's acne.

Augmedix's mission is to re-humanize healthcare and enhance the patient experience. This means that they aim to bring back the human touch in healthcare by using technology to improve the overall patient experience. They likely achieve this by providing solutions that streamline administrative tasks for healthcare providers, allowing them to spend more time with their patients and provide better care. By stating that the answer is true, it confirms that Augmedix indeed has a mission to re-humanize healthcare and enhance the patient experience.

As a scribe, it is important to be aware of the schedule so that you can anticipate the visit type and when the patient is ready to be seen by the provider. This allows for efficient workflow and ensures that the provider can see the patient in a timely manner. Notifying the provider or stating that you are ready to see the patient are not the primary responsibilities of a scribe in this situation. Leaving for a break would be inappropriate during working hours.

The most common way for a patient to establish care with a specialist is when their Primary Care Provider determines the need for a specialist and gives the patient a referral. The patient can then schedule an appointment with the specialist. This process ensures that the patient receives appropriate care and that their medical history and relevant information are shared between the Primary Care Provider and the specialist.

Health insurance in the U.S. serves multiple purposes. Firstly, it helps to protect individuals from catastrophic financial risk by providing coverage for medical expenses. Secondly, health insurance can be obtained through various means, including privately purchased plans, social insurance programs, or government-funded social welfare programs. Lastly, health insurance plans can differ in terms of the benefits they offer and the restrictions they impose. Therefore, all of the statements mentioned in the options are true regarding health insurance in the U.S.

In the event of a car accident and critical injuries, the most appropriate healthcare facility to receive immediate medical treatment would be the Emergency Room. Emergency Rooms are equipped to handle life-threatening situations and provide urgent medical care. They have specialized staff, equipment, and resources to stabilize patients and provide necessary interventions. Medical Offices and Urgent Care centers may not have the same level of emergency care capabilities, while hospitals may have different departments for specialized treatments and may not be the initial point of contact for immediate critical care.

The correct answer is "Subjective, Objective, Assessment, Plan." The SOAP note acronym is a widely used method of documentation in healthcare. The subjective section includes information provided by the patient, such as their symptoms and medical history. The objective section includes measurable data obtained by the healthcare provider, such as vital signs and physical examination findings. The assessment section includes the healthcare provider's evaluation and diagnosis based on the subjective and objective information. The plan section includes the recommended treatment, medications, and follow-up instructions.

A primary care provider would refer their patient for treatment of advanced rheumatoid arthritis to a rheumatologist. Rheumatology is the medical specialty that focuses on the diagnosis and treatment of conditions related to the joints, muscles, and bones, including rheumatoid arthritis. Rheumatologists have specialized knowledge and expertise in managing and treating rheumatic diseases, making them the most appropriate specialists to address the needs of patients with advanced rheumatoid arthritis.

The correct answer is Augmedix Scribe Training (AST). This phase refers to the specific training program called Augmedix Scribe Training (AST) that the individual is currently in. It is a training phase that focuses on teaching individuals the skills and knowledge required to become a scribe for Augmedix, a company that provides medical scribe services. During this phase, trainees learn about medical terminology, documentation practices, and other relevant skills necessary for their role as a scribe.

A patient with headaches and migraines would typically be treated by a healthcare specialist in the field of neurology. Neurologists specialize in diagnosing and treating disorders of the nervous system, including conditions that cause headaches and migraines. However, it is also possible for a patient to initially seek treatment from a primary care physician, who may then refer them to a neurologist for further evaluation and management. Therefore, both neurology and primary care can be involved in the treatment of patients with headaches and migraines.

The subjective section of the SOAP note is a documentation of the patient's subjective complaints, symptoms, and information provided by the patient. It includes the patient's medical history and current medications as these are important factors in understanding the patient's condition. However, the provider's treatment plan is not included in the subjective section as it belongs to the assessment and plan sections of the SOAP note.

The correct answer is "may affect the safety, care, or treatment of the patient." This is because a critical error in scribe notes has the potential to impact the safety, care, or treatment of the patient. It implies that the error is significant enough to potentially cause harm or hinder the quality of care provided to the patient.

The statement "There was a cake at my nephew's wedding which was tempting but I held back" would be the least medically relevant because it does not directly address the patient's weight loss progress or any factors related to their health. While it may indicate some level of self-control, it does not provide any information that is medically significant in the context of a weight loss follow-up.

To move on to an Implementation or a Transition, a trainee must pass either the Doctor Approval (DA) Audit or the Doctor Ready (DR) Audit. The Final Exam Shadowing (FES) is not mentioned as a requirement for progressing to these stages. Therefore, the trainee must pass 2 of the above options, which are DA Audit and DR Audit.

The quotes "Provider: 'Jack, on exam, you have clear breath sounds, bilaterally'" and "Provider: 'Jack, your labs show that your White Blood Cell Count is elevated'" would be considered "objective" because they are based on observable facts and measurable data. These statements do not involve personal opinions or subjective interpretations.

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Transcriptionists and scribes have several differences. Transcriptionists listen to recorded dictations while scribes observe patient visits in real-time. Transcriptionists write down what they hear word for word, whereas scribes listen to determine important information and then convert it into a cohesive note. Transcriptionists have the ability to rewind a dictation if they miss something, but scribes cannot rewind visits. However, scribes can ask questions to the provider if they miss something. Lastly, transcriptionists do not communicate with providers, whereas scribes communicate, collaborate, and build a real relationship with their provider.

The passing criteria for the Final Exam Shadowing (FES) is to have an average score of 40/50 (80%) on the last 5 notes. This means that the student must score at least 80% on each of the last 5 notes in order to pass the exam.

The next 5 weeks of Augmedix Scribe Training (AST) can be expected to include lecture-based learning, interactive learning, shadow shifts for creating practice notes, a goal to understand the fundamentals of medical documentation and reasoning, and quizzes on lecture material.

The final checkpoint before entering live production is the Doctor Approval (DA) Audit. This audit ensures that all necessary approvals and checks have been completed by the doctors involved in the production process. It verifies that the production is aligned with the required standards and meets all the necessary criteria before being released for live production.

When documenting a provider's treatment plan for the patient, it is the responsibility of a scribe to listen attentively to the information the provider is telling the patient. This ensures accurate and complete documentation of the treatment plan. Additionally, the scribe should associate the plan details with the correct assessment to ensure proper organization and clarity in the documentation.

If a patient wants to follow up with their primary care doctor about their medication regimen, they would most likely visit Medical Offices. This is because primary care doctors typically work in medical offices where they provide routine check-ups, manage chronic conditions, and prescribe medications. The other options, such as the Emergency Room, Urgent Care, and Hospital, are more suitable for immediate or emergency medical needs rather than routine follow-ups with a primary care doctor.

As a scribe, your role is to listen closely for all medically relevant information and write it down accurately. You should also take note of any questions you may have for the provider, as this can help in clarifying any uncertainties. Additionally, it is important to convert the medically relevant information into a cohesive and clear medical note, ensuring that it is organized and easy to understand for future reference.

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The correct order of events during a normal patient visit is to first check in, then record vitals, followed by discussing the reason for the visit, conducting a physical exam, and finally deciding on a care plan.

The correct answer is "2 of the above" because both Psychiatry and Primary Care specialties can treat patients with depression and anxiety. Psychiatry specifically focuses on the diagnosis, treatment, and prevention of mental disorders, including depression and anxiety. Primary Care physicians, on the other hand, are often the first point of contact for patients seeking medical care and can provide initial assessment and treatment for mental health conditions like depression and anxiety before referring patients to a specialist if necessary.

The medical note serves multiple purposes. Firstly, it provides a chronicle of the patient's medical history and care, allowing healthcare professionals to have a comprehensive understanding of the patient's health. Additionally, it serves as the primary means of communication between members of the healthcare team, ensuring that everyone involved in the patient's care is informed and on the same page. Moreover, the medical note is a legal document that can be used in a court of law as evidence or documentation. Lastly, it is necessary for billing payment and provider reimbursement, as it contains important information regarding the services provided to the patient.

A primary care physician might refer a patient to a specialist because they would like a second opinion from a provider with more experience in a certain field, because the patient has requested a referral to a specialist, and because they are unsure of the best way to treat a condition. Referring to a specialist can provide the primary care physician with additional expertise and knowledge to ensure the patient receives the best possible care. Additionally, if the patient specifically requests to see a specialist, the primary care physician may refer them to fulfill their preference. Lastly, if the primary care physician is uncertain about the most effective treatment approach, they may refer the patient to a specialist for further evaluation and guidance.

The SOAP note is a documentation method used by healthcare providers to record patient information. In this context, the term "assessment" refers to the provider's impression or diagnosis of the patient's condition. The term "plan" refers to the treatment or actions that the provider will take to address each assessment. Therefore, the correct answer is "Assessment, assessment, Plan, plan."