Essential Scribe Entrance Exam Test Questions With Well Elaborated Solutions

Essential Scribe Entrance Exam Test Questions With Well Elaborated Solutions Which of the following are sections of a patient's medical record? (Check all that apply). past Medical History Review of Sections Present Examination Review of Systems History of Patient's Symptoms Medical History Making History of Present Illness Past Symptom History Physical Examination - ANSWER -Past Medical History Review of Systems History of Present Illness Physical Examination What is the name for the clinical summation of information and/or the opinion based on the patient's symptoms, their clinical history, and the outcome of the objective data? - ANSWER -Diagnosis What are Patient Instructions? - ANSWER -A shorter, easy-to-read version of the Plan that is given to the patient. Who provides the findings that are documented in the Physical Exam? - ANSWER -Medical Provider Which of the following would be included in a Plan? (Check all that apply). Changes in medications/new medications being prescribed. Conversations with other providers during the treatment of the patient. Orders for labs, imaging, or other additional testing. A list of symptoms reported by the patient. All communications with nursing staff. Referrals to other healthcare professions. - ANSWER -Changes in medications/new medications being prescribed. Orders for labs, imaging, or other additional testing. Referrals to other healthcare professions. Which of the following is a Reason for Visit and which note section could this be documented in? - ANSWER -Chest pain, History of Present Illness (HPI) Which of the following are considered diagnostic studies? (Check all that apply). Differential diagnosis Consultations Labs Procedures Imaging Reevaluations - ANSWER -labs, imaging The ambulatory care setting refers to high acuity environments, such as an ICU, and an acute care setting refers to low acuity environments, such as a primary care clinic. - ANSWER -false A single encounter note is used to document each patient's unique visit with a medical provider. - ANSWER -true Select the correct past history section for the following: History of hysterectomy Past History Sections: (Medical, Surgical, Family, Social) - ANSWER -surgical Select the correct past history section for the following: Patient smokes half a pack of cigarettes a day Past History Sections: (Medical, Surgical, Family, Social) - ANSWER -social Select the correct past history section for the following: History of recurrent urinary tract infections (UTIs) Past History Sections: (Medical, Surgical, Family, Social) - ANSWER -medical Select the correct past history section for the following: Brother has diabetes Past History Sections: (Medical, Surgical, Family, Social) - ANSWER -family Subjective information is: - ANSWER -Information from the patient Information from the family Objective information is: - ANSWER -Information from the provider What is the Reason for Visit? - ANSWER -The Reason for Visit is the main reason a patient is being seen by the provider. Which is an appropriate definition and example of an acute complaint? - ANSWER -An acute complaint is a new symptom or problem a patient would like evaluated, such as chest pain. Why would a patient be seen in the acute care setting for a medication refill? - ANSWER -They were unable to obtain a refill from their usual provider and are in need of a short-term supply. What is the difference between a visit to establish care versus an initial consultation? - ANSWER -A visit to establish care occurs with a primary care provider, whereas initial consultations are reserved for specialty providers. What is the difference between a routine follow up visit versus an urgent follow up visit? - ANSWER -A routine follow up visit occurs at scheduled intervals for continued evaluation and monitoring of chronic medical conditions, whereas urgent follow up visits address a new symptom, side effects from medications, or other urgent/emergent concerns related to a chronic medical condition. Which of the following would be considered a typical routine follow up visit? - ANSWER -A patient with diabetes who needs labs and a medication refill. What is the Reason for Visit often called? - ANSWER -Chief complaint What should a patient do after being seen for an acute care visit? - ANSWER Follow up with their primary provider to evaluate their progress. HPI for acute care setting - ANSWER -patient is a [age] with a history of [blank] who...