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I just subscribed to this channel on the you tube, I was witching this video on the you tube, and I really enjoy watching this video on the you, hope you keep posting more of these videos on the you tube ❤

this is an older video, nowadays it is all done remotely, meaning the scribe works from home and opens the patient software program and charts live. I dont know if they have any camera viewing for privacy reasons, I think it is just a live audio feed. Soon AI will do it anyway.

I have bad anxiety over this and don't know if I want to do it :( I hear a lot of horror stories about mean doctors and I am a sensitive person. I want to be a nurse and I know I have to toughen up but I am very scared!

Carlos Inlet

can someone please give tips how to transcribe accurately if its as muffled as this? huhu

Loved the video, the music was quite annoying.

Free Electronic Medical Records (EMR) with complete Revenue Cycle Management (RCM) How to enter History of Present Illness (HPI) in the EMR Module ruclips.net/video/9DmeY4IgwYA/видео.html

Shifting from being a respiratory therapist to being a medical scribe this actually make sense thankyou <3

He say he doesnt have no history of UTI

Question is the video recorded and can you repeat it to write down something you miss and correct ?

This is so helpful but I just hope if you could tone down the background music or removing it completely. But nevertheless... this is insightful and informative. Thank you!

A demo training to be a Jonathan.

Meeting drohanon on RUclips has really been one of the best day of my life after years of suffering I have finally been cured for My bad breath.😊

Imagine a Karen as a patient. Yes, I have a few experiences with them.

Hallo😮

what were the medicines? singulair and?

What is the best way to edit the HPI for follow up & ongoing visits?

damn the back ground music is quite loud

this is more detailed and helpful than my job training lol

A XX-year-old male patient presents with chest pain and a lip laceration. He reports being in a car accident half an hour ago while driving to a dinner, during which his chest and face hit the steering wheel. He confirms the vehicle's speed was 35 mph, he was not wearing a seatbelt, and the airbag did not come off. He notes pain in his right ribs and some discomfort in his shoulder but denies abdominal pain. The patient also has hypertension but denies taking any blood thinners or aspirin. He confirms being able to walk around.

A XX-year-old presents with back pain. The patient reports that yesterday evening, while doing deadlifts, she felt a pop in her lower back while trying to get the position right. Despite this, she continued for a couple more rounds. She mentioned returning to the gym after 5 years to start a healthy lifestyle but may have overexerted herself. The pain initially started as on and off but gradually became constant. She describes the pain as a spasm that radiates to both of her legs and rates it as 7/10. Certain movements, lying flat, and twisting aggravate the pain, while breathing and distracting herself bring temporary relief. Sitting with a high angle brings relief too. The patient denies any past back problems, only typical soreness. She has not taken any medication to relieve the pain as she was attempting to maintain a healthy lifestyle. Furthermore, she denies any bowel incontinence, urine frequency or urgency. She also denies weakness in her legs, fever, and can walk normally.

A XX-year-old presents with back pain. The patient reports that yesterday evening, while doing deadlifts, she felt a pop in her lower back while trying to get the position right. Despite this, she continued for a couple more rounds. She mentioned returning to the gym after 5 years to start a healthy lifestyle but may have overexerted herself. The pain initially started as on and off but gradually became constant. She describes the pain as a spasm that radiates to both of her legs and rates it as 7/10. Certain movements, lying flat, and twisting aggravate the pain, while breathing and distracting herself bring temporary relief. Sitting with a high angle brings relief too. The patient denies any past back problems, only typical soreness. She has not taken any medication to relieve the pain as she was attempting to maintain a healthy lifestyle.

This is awesome. Thank youuuu!!

SUBJECTIVE: HPI-ROS: The patient states that she has been experiencing a sore throat for the past 5 days which keeps getting worse. She mentioned her family and friends, whom she'd been with at a birthday party a couple of days ago were sick. She also shared the same drink with her friend. She affirms having a fever, experiencing having a hard time swallowing, a swollen neck, and light-headedness. She already consulted a doctor who thought it was strep and was prescribed Amoxicillin but it doesn't relieve her sore throat. She noticed some rash in her abdomen but doesn't itch. She mentions there's a pain on the left side of her stomach. She denies cough, shortness of breath, chest pain, vomiting, nausea, change in bowels, urinary symptoms like burning, frequency & urgency, weak pain, and swelling. She also denies major illnesses and surgeries in the past. REVIEW OF SYSTEMS: General: Positive for fever, no change in strength or exercise tolerance. Head: Notable for light-headedness. Mouth: Positive for sore throat, no dental difficulties, no gingival bleeding, no use of dentures. Neck: Positive for swelling, no stiffness, no pain, no tenderness, no noted masses. Abdomen: Positive for left abdominal pain and abdominal rashes, no change in appetite, no dysphagia, no bowel habit changes, no emesis, no melena. OBJECTIVE: General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect. Eyes: Notable for blurry vision, no diplopia, no tearing, no scotomata, no pain. Nose: She has a dry mucous membrane, no epistaxis, no coryza, no obstruction, no discharge. Throat: She has pharyngeal erythema with exudates, hypertrophic tonsils, and moderate dysphonia with biochismism. Neck: She has anterior submandibular adenopathy and posterior cervical adenopathy. Heart: She has tachycardia with S4 gallop, 1 over 6 systolic ejection murmur. Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of accessory muscles of respiration. Abdomen: She has a sore in the spleen edge one-finger breath below the left costal margin, Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.

The patient states that he has been experiencing sudden headaches for 8 hours ago which have been constant while working at his desk. The patient describes his headache as throbbing, with a pulse, and light makes it much worse. He rates his pain as 8 or 9 out of 10. He affirms feeling nauseous, unable to see straight, has blurry vision, and is dizzy. Additionally, he claims that his neck is stiff and painful to move. He has tried Imitrex and Motrin but it doesn't work to relieve his pain. He denies fever, chills, sweats, rash, cough, nasal congestion, sore throat, weakness, difficulty speaking, belly pain, and diarrhea. He affirms having migraine for his entire life, taking Imitrex for this condition, and going to a neurologist every time it gets bad.

SUBJECTIVE: HPI-ROS: The patient presents today after experiencing a stuffy and runny nose for the past week which has been gradual. He states that he feels much pressure on his nose, drainage on the back of his throat, and has a frontal headache. He also mentioned his little brother had the same symptoms as him. He denies having a fever, light sensitivity, neck stiffness, nausea, diarrhea, belly pain, and weakness. He admits having a little bit of cough with clear discharge. He affirms having a seasonal allergy, and admits taking Sudafed & DayQuil which hasn't helped that much), plus, an Afrin inhaler for congestion. He also had a history of asthma. REVIEW OF SYSTEMS: General: Generally healthy, no change in strength or exercise tolerance. Head: Positive for frontal headaches, no vertigo, no injury. Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: No change in hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no coryza, no obstruction, no discharge. Mouth: No dental difficulties, no gingival bleeding, no use of dentures. Neck: No stiffness, no pain, no tenderness, no noted masses. Chest: Positive for mild cough, No dyspnea, no wheezing, no hemoptysis. Heart: No chest pains, no palpitations, no syncope, no orthopnea. Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena. GU: No urinary urgency, no dysuria, no change in nature of urine. Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesia or numbness. Neurologic: No weakness, no tremors, no seizures, no changes in mentation, no ataxia. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content. OBJECTIVE: General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect. Eyes: Pupils equal round and reactive, extraocular muscles intact. Conjunctiva clear no injection or discharge, sclera non-icteric. Ears: EACs clear, TMs normal bilaterally. Nose: Mucosa normal, no obstruction, no discharge. Throat: He has cobble stoning and erythema, plus two tonsils bilaterally, no exudates, no lesions. Neck: He has anterior cervical lymph node swelling, No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs. Heart: He has mild tachycardia, no murmurs, no rubs, no gallops. Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of accessory muscles of respiration. Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits. Back: Normal curvature, no tenderness. Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact. ASSESSMENT: 1. Bilateral maxillary sinusitis PLAN: 1. Strep swab to determine whether the patient had strep throat

She is laughing too much from inside and she is trying not to laugh. By the way, she is cute.

Mam i have one doubt lets clarify plz Whethere medical scribe need to system😊

I started my medical scribe training and I have been struggling to write a good HPI. This is exactly the video that I needed! Thank you so much! :)

Cc: DOB HPI : The patient has been experiencing asthma attack for the past 3 weeks. She affirms coughing with blood, phlegm in green and yellow color. She has tried steroids for 2 weeks, and currently taking ***** and Singulair. She affirms smoking since 20 yrs old. She denies N&V, rashes, diarrhea, pain swelling, palpitations nor head ache, also she denies seeing anyone since her steroid tx. increase respiratory pharse, bilateral wheezing few scattered bronchi, borderline tachycardia abt 100. Plan : pre&post peak flow with breathing tx. - check CBC, Lateral x-ray - Steroids through IV

The bg music is so distracting

White ppl always with their stupid long stories, get to the point!! 🙄

Please remove the background music 🎵

Pt is a 24 year old female who presents on 2.19.2024 after using cocaine yesterday on 02.18.2024. She tells us the police thought she should be here- that they drove her to the hospital because they did not like what she was doing. She remembers running around the street in the morning in a busy area and saw three squirrels. She was “playing a game” running in between cars when the police stopped her from doing this. Pt denies suicidal thoughts, just playing games, no thoughts of hurting others. The patient denies hearing voices or sensation of bugs. She does say she sees bugs in the medical suite. She had “some dreams” last night when asked if she had slept at all. There is a chance she could be pregnant. She had a temperature of 95 three days ago that she believes she was able to find by palpating her mouth with her finger. She remembers her temperature today is 98.2 from when the nurse took it this morning. She does not take anything for asthma or depression. Her mom does. She does not want to go home to her mother because she is “going to lock her up.” She does give consent to call her mother. She persists on getting lunch with the crisis worker because she is hungry. She does mention she gets lonely when by herself in the medical suite.

This will help me as a new medical coder and biller!

Good effort mam 👏🏻

PULMONARY DYSPNEA CP HPI Patient is a 25 year old female presenting today 02.01.2024 with symptoms of right chest pain. The onset of chest pain was last evening. The patient has been under stress recently and thought that the chest pain may stem from this. She had a rough home life growing up and left home when she was eighteen. She attributes this to her anxiety. She does not take any medications for this. When she woke up this morning she did not feel right. She was experiencing dyspnea. There is a sharp pain in her chest when she inhales. She is a heavy smoker and will smoke over one pack a day normally. She does not have any asthma. She mentioned she had a typical migraine headache this morning for which she took Imitrex for She denies any cough, sore throat, fever, congestion, nausea, belly pain or neck pain. She also takes birth control. HEART: Tachycardic rate of 110 LUNGS: Slightly diminished breaths on right lung base EXTREMITIES: Negative Homans sign 1) Chest Pain Smoking, birth control and heart rate are all risk factors for blood clots Will need get a cat scan Urine pregnancy test EKG-nsr the rate 110 access right access she does have an s1 q1 t3 and no st elevation or depression no bbb summary would be a s1 q3 t3 tachycardia otherwise normal -order Basic labs CBC, BMP Try breathing treatment to see if there is any improvement to symptoms.

This was really helpful but the background music makes it hard to hear the conversation between the patient and physician.

Patient presents to the clinic with chronic abdominal pain in her upper middle quadrant which is constant. Describes pain as like someone is holding her tight. Rates pain 5 out of 10 in the pain scale. Affirms vomiting twice this morning after waking up. Affirms diarrhea without blood and mucus. Patient has been taking pregabalin with temporary relief. Had fentanyl patch with slight relief. Denies urinary symptoms, fever, chest pain, cough, shortness of breath, passing out, rash, leg pain and swelling. Admits visiting Dr. Sachmen 3 weeks ago intially suspecting appendix. Admits that uterus, overies, and gallbladder have been surgically removed. Admits pancreatitis. Admits feeding through J tube. Reports being treated in Indiana for OD dysfunction. Recalls being diagnosed with gastrointestinal problem by family doctor, Dr. Bennette.

Patient presents to the clinic with hematemesis for the past 3 days. Describes blood as dark blood which resembles coffee brown. Affirms belly pain when vomiting. Affirms dizziness. Reports that his stool is black. Claims that his heart is racing. Denies shortness of breath and chest pain. Recalls one episode of bright red blood vomit and was told that it was due to something in his esophagus. Admits drinking everyday every time he wakes up and before going to bed. Admits that he is undergoing testing for liver cirrhosis. Admits that his dad has peptic ulcer. Denies heart and lung problems.

I did pharm.D and worked in hospital for morethan 1 yr still I need to take training outside in institutes or else shall I apply dieectly

Patient presents to the clinic with palpitation for the past 3 days which has been sudden and lasts for 15 minutes. Recalls that she had palpitations today that lastd for 30 minutes. Affirms fast and pounding chest making it hard to breathe. Recalls hair loss and weight loss of at least 20 lbs. Reports having diarrhea for the past 6 months. Affirms headache. Experiences diminished appetite. Denies fever, cough, belly pain, urinary symptoms, leg pain, rash, and vision change. Denies any history of palpitations.

A 25-years old female patient presents to the clinic with shortness of breath after waking up this morning. Describes pain as sharp pain every time she breathes. She claims to have trouble breathing and pain during inhalation. Affirms headache but has taken imitrex with relief. Patient also affirms tingling in her hands. Denies lung problem, cough, sore throat, fever, congestion, nausea, leg pain and swelling, and pregnancy. She attributes her pain to her stress and anxiety. Claims that she has a rough childhood growing up and has been independently living on her own paying bills. Affirms taking birth control. Affirms smoking one and a half pack a day. Denies recent travel and surgery. Affirms that her dad has clotting problems. Denies family history of heart disease.

Patients presents to the clinic with headache onset 8 hours ago while working at his desk. Pain is sudden and constant at either side of his head. Describes pain as throbbing like a pulse. Rates pain 8 or 9 out of 10 in the pain scale. Patient has tried imitrex with no relief. Patient affirms nausea, vomiting, and dizziness. Patient claims that he started having blurry vision and couldn't see straight. He claims that light makes his headache worse. Claims that his neck got stiff and is painful when move. Denies fever, chills, sweats, rash, nasal congestion, cough, weakness, diffuculty walking, belly pain, diarreha and vision loss. Admits that he has a history of migraine and has been taking imitrex. Denies knowing anyone with similar symptoms as his.

I sure wish I could have watched this w/o the background music. It made it harder to hear what was going on and was distracting. Otherwise a great video!

I just can't believe how generous you are by sharing this content. In my view people like you are the ones who really stand out in society!

Kelly ji I LOVE YOU 💍💍💑👍👌🌷🌷🌹🌹🌺🌺❤❤💌💌🌸🌸

Been a scribe for 6 months now. I have been doubting my abilities since I got sent home early 3 days ago. What you demonstrated is exactly what I do on a daily basis. I guess I just have some provider's who are non communicative and have unrealistic expectations of someone who hasn't finished med school yet.

Is this offline scribe or real-time????