AST V3 Lecture 6 Assessment

The assessment and plan are determined by the provider. The provider is the healthcare professional who is responsible for diagnosing and treating the patient. They have the knowledge and expertise to assess the patient's condition, make a diagnosis, and develop a treatment plan. The provider takes into account the patient's medical history, symptoms, and test results to determine the appropriate course of action. The medical assistant, scribe, and patient may provide information and support in the decision-making process, but ultimately it is the provider who makes the final determination.

As a scribe, it is not the job to decide the diagnosis for the patient. The role of a scribe is to accurately document the physician's observations, diagnoses, and treatments. The decision of the diagnosis is the responsibility of the physician based on their expertise and evaluation of the patient's symptoms and medical history. Therefore, the statement is false.

The statement suggests that as a scribe, it is the job of the individual to take the plan details and rephrase them using standard medical language. This implies that organizing and using proper medical terminology is a crucial part of the scribe's role. Therefore, the correct answer is True.

The lab order that contains the lab tests WBC, Hgb, HCT, Platelets, and RBC is the Complete Blood Count (CBC). The CBC is a common blood test that provides information about the different types and numbers of cells in the blood, including white blood cells (WBC), red blood cells (RBC), hemoglobin (Hgb), hematocrit (HCT), and platelets. It is often used to evaluate overall health, screen for various conditions, and monitor the effectiveness of treatments.

The statement is false because a diagnosis/impression included in the A/P (Assessment/Plan) does not have to be absolute and definite. In medical practice, sometimes there may be uncertainty or the need for further testing before a definitive diagnosis can be made. Therefore, a diagnosis or impression included in the A/P can be provisional or tentative, indicating that it is subject to further evaluation or confirmation.

Assessments should be organized according to Augmedix's standard Assessment/Plan Style by listing them in order of most to least significant. This means that the most important assessments should be listed first, followed by the less significant ones. This organization helps prioritize the assessments and ensures that the most critical information is easily accessible and highlighted.

No assessment is clear based on this conversation. Therefore, no assessment should be inputted by the scribe until the provider has clarified.

The provider advised the patient to call the office if symptoms persist or worsen, and to schedule an appointment with Dr. Hansen, a specialist, to address the rash on the patient's right thigh.

A differential diagnosis refers to a group of diagnoses that share similar signs and symptoms. This means that there are multiple possible diagnoses that could explain the patient's symptoms, and it is uncertain which one is the correct diagnosis. The healthcare provider must consider all the possibilities and gather more information to make a final diagnosis.

The correct answer is "Smoking cessation advised" because it is a concise and professional way to convey the message of advising the patient to stop smoking. It captures the essence of the provider's statement without any additional information or direct quotes.

Prescribed Ativan 1mg prn for anxiety.

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Providers are reimbursed for the care they provide based on ICD-10 codes. These codes are used to classify and report diagnoses, symptoms, and procedures, allowing healthcare providers to accurately document and bill for their services. Reimbursement is typically determined by insurance companies and government payers who review the ICD-10 codes submitted by providers to determine the appropriate payment for the care provided.

As a scribe, it is not your responsibility to know ICD-10 codes for common diagnoses. Your role is to assist healthcare professionals by documenting patient encounters accurately and efficiently. While having knowledge of common diagnoses and medical terminology is beneficial, it is not a requirement for the position. The responsibility of assigning ICD-10 codes typically falls on medical coders or billing specialists who have specialized training in coding and reimbursement.

The other plan details mentioned in the options are all related to medical concerns and instructions, such as discussing potential side effects of a medication, applying warm compresses, and maintaining a healthy diet. However, the last option about running at a medium pace at night and avoiding wheat prior to exercise does not directly pertain to a medical condition or treatment. It seems to be more focused on personal fitness and dietary preferences rather than a medically relevant plan detail.

The provider is referring to "PT" as an abbreviation for "Physical therapy." In this context, the provider is stating that they will be writing a script or referral for a patient to receive physical therapy services from Ed in the department.

The given options consist of medical conditions, and the question asks for the least likely assessment. Assessments typically involve evaluating or diagnosing a condition or injury. Lipoma, back pain, and scoliosis are all medical conditions that could be assessed. However, a shoulder injury is more likely to be assessed rather than being an assessment itself. Therefore, the least likely assessment among the given options is a shoulder injury.

The provider's statement indicates that the patient will be waiting in radiology, suggesting that an imaging study has been ordered and will be conducted immediately.

The way this A/P should be written depends on the preferences of the provider. Different providers may have different preferences for formatting and organization. Some may prefer a list format, while others may prefer paragraph form or shorthand notation. Therefore, the correct answer is that it depends on the provider's preferences.

The dialogue suggests that the patient should be referred to physical therapy, indicating that it is an important component of the plan. Additionally, the dialogue mentions that an order was placed for a thoracolumbar series, indicating that it should also be included in the plan. The other options, scheduling lipoma excision surgery and continuing the current diet regimen, are not mentioned in the dialogue and therefore should not be included in the plan.

The dialogue mentioned in the question implies that there is a need to input certain assessments into the EHR. Therefore, it is logical for the scribe to ask which assessments should be inputted. Hence, the correct answer is "True".

During the visit, the following topics were discussed: back pain, mass of fat over the shoulder blade, bone density screening, and osteopenia risk factors.

The dialogue mentioned a discussion about plan details, which implies that different options were considered or talked about. Referrals, surgical intervention, and imaging were specifically mentioned as topics of discussion. However, there is no mention of medication being discussed, so it is not one of the plan details that were discussed.

The dialogue provides information about the onset/duration of the rash (appeared a few days ago), the patient's complaint (weird rash on right thigh), the provider's plan (referring to a dermatology clinic and suggesting making an appointment), the location of the rash (right thigh), and the timing of seeking medical attention (if symptoms worsen). The dialogue does not provide any information about assessment or exam findings.

The provider would want the imaging results to assess the lipoma and determine any potential complications or treatment options. The lipoma exam findings would provide further information about the size, location, and characteristics of the lipoma. The absence of physical symptoms related to the lipoma would indicate that it is not causing any discomfort or complications. Scoliosis may or may not be related to the lipoma, but it is important to include in the A/P as it is a separate condition that needs to be addressed.

The A/P can be a combination of all information from the note. If the provider wants to include his/her medical reasoning based on subjective information, objective information, imaging impressions, all of that can be included in the A/P.

An imaging impression is likely to be recorded or discussed in the HPI (History of Present Illness), PE (Physical Examination), and A/P (Assessment and Plan) sections. The HPI allows the healthcare provider to gather information about the patient's symptoms and medical history, including any relevant imaging studies. The PE involves a physical examination, which may include the interpretation of imaging findings. Finally, the A/P section summarizes the provider's assessment of the patient's condition, including any imaging impressions and the plan for further evaluation or treatment.