MEDICAL SCRIBE Final Exam with Complete Solutions

Expand the following medical abbreviation into the full medical term. What does "DOE" mean? - ANSWER-Dyspnea on Exertion Expand the following medical abbreviation into the full medical term. What does "PE" stand for in the diagnosis section of the chart? - ANSWER-Pulmonary Embolism Expand the following medical abbreviation into the full medical term. What does "CSF" stand for? - ANSWER-Cerebrospinal Fluid Expand the following medical abbreviation into the full medical term. What does "DVT" stand for? - ANSWER-Deep Vein Thrombosis Expand the following medical abbreviation into the full medical term. What does DP stand for in "DP pulse"? - ANSWER-Dorsalis Pedis Expand the following medical abbreviation into the full medical term. What does "CVA" stand for in the PE section? - ANSWER-Costovertebral Angle Expand the following medical abbreviation into the full medical term. What does "PTX" stand for? - ANSWER-Pneumothorax Expand the following medical abbreviation into the full medical term. What does "CBC" stand for? - ANSWER-Complete Blood Count Expand the following medical abbreviation into the full medical term. What does "PNA" stand for? - ANSWER-Pneumonia Expand the following medical abbreviation into the full medical term. What does "s/p" stand for? - ANSWER-status post Expand the following medical abbreviation into the full medical term. What does "CHF" stand for? - ANSWER-Congestive Heart Failure Expand the following medical abbreviation into the full medical term. What does "TIA" stand for? - ANSWER-Transient Ischemic Attack Expand the following medical abbreviation into the full medical term. What does "COPD" stand for? - ANSWER-Chronic Obstructive Pulmonary Disease Expand the following medical abbreviation into the full medical term. What does "LBBB" mean? - ANSWER-Left Bundle Branch Block Expand the following medical abbreviation into the full medical term. What does "URI" stand for? - ANSWER-Upper Respiratory Infection Expand the following medical abbreviation into the full medical term. What does "IDDM" stand for? Do not use hyphenations in your answer. - ANSWER-Insulin Dependent Diabetes Mellitus Expand the following medical abbreviation into the full medical term. What does "AMS" stand for? - ANSWER-Altered Mental Status Expand the following medical abbreviation into the full medical term. What does "DNR" stand for? - ANSWER-Do Not Resuscitate Expand the following medical abbreviation into the full medical term. What does "AAA" stand for? - ANSWER-Abdominal Aortic Aneurysm Expand the following medical abbreviation into the full medical term. What does "GCS" stand for? - ANSWER-Glasgow Coma Scale Expand the following medical abbreviation into the full medical term. What does "NTG" stand for? - ANSWER-Nitroglycerin Expand the following medical abbreviation into the full medical term. What does "EOMI" stand for? (Hint: 3 words) Do not use hyphenations in your answer. - ANSWER-Extraocular Movements Intact Expand the following medical abbreviation into the full medical term. What does "GERD" stand for? (Hint: 3 words) - ANSWER-Gastroesophageal Reflux Disease Among the following diseases listed, select the ones that qualify for CCT. • Pleuritis • Costochondritis • ACS • CVA • A-Fib with RVR • Acute MI • DKA • PTX • Stable angina • PE • Sepsis - ANSWER-• ACS • CVA • A-Fib with RVR • Acute MI • DKA • PTX • PE • Sepsis Which of these procedures qualify as critical care procedures and would indicate that CCT must be documented on a Pt? Select all that apply. • Arthrocentesis • Sedation • LP • Cardioversion • Central line placement • Chest tube • CPR • Intubation • CPAP/BiPAP - ANSWER- Match each critical care Dx with its associated procedure. 1) Respiratory failure 2) Acute exacerbation CHF/COPD (Severe) 3) Cardiac arrest 4) PTX 5) Sepsis 6) Abnormal heart rhythm Choices: CPAP/BiPAP • Chest tube • Intubation • Cardioversion • Central line placement • CPR - ANSWER-1) Intubation 2) CPAP/BiPAP 3) CPR 4) Chest tube 5) Central line placement 6) Cardioversion Critical Care must be at least a minimum of _____ a) 25 minutes b) 30 minutes c) 35 minutes d) 60 minutes - ANSWER-30 minutes A 45 y/o male presents to the ED with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What element is "constant"? a) CC b) Onset c) Timing d) Location e) Quality f) Severity g) Pertinent Positive/Pertinent Negative h) Modifying Factor i) Relevant Context - ANSWER-Timing A Pt has the following Hx: Breast CA s/p chemoradiation therapy and mastectomy. Based on this, does the Pt meet Level 5 billing criteria for this section of the chart? a) Yes, the PHx meets Level 5 billing criteria b) No, the PHx does not meet Level 5 billing criteria - ANSWER-No, the PHx does not meet Level 5 billing criteria (PMHx & PSHx count together, need at least 2 Hx elements: PMHx/PSHx, SHx, FHx) Read through the PE and decide if this meets Level 5 billing criteria. -General/Constitutional: NC, AT -Eyes: PERRL, EOMI -ENT: Moist oral mucosa -Cardiac: Irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no gallops -Respiratory: Lungs clear, no respiratory distress, no wheezing, no rales, no rhonchi -Neurological: A&O x4 -Psychiatric: Normal affect a) Yes, the PE meets Level 5 billing criteria b) No, the PE does not meet Level 5 billing criteria - ANSWER-No, the PE does not meet Level 5 billing criteria (Needs at least 8 different systems) What are the possible consequences of a HIPAA violation? Select all that apply. • Termination • Monetary fines to you and the hospital • Prison time • Lawsuit against you and the hospital • Violator is blacklisted from medical programs like Medical, PA, or NP school • Scribe program cancellation - ANSWER-• Termination • Monetary fines to you and the hospital • Prison time • Lawsuit against you and the hospital • Violator is blacklisted from medical programs like • Medical, PA, or NP school • Scribe program cancellation George is employed with SA as a scribe. He was off today and accidentally cut his cheek while practicing his sword swallowing skills. He goes to the ED and is seen by a doctor and another scribe. The ED is extremely busy, and so George decides to help out the doctor by scribing his own note using the computer in the room. Has George taken the appropriate steps in this situation? a) No, this is a HIPAA violation because George is sharing Protected Health Information b) Yes, this is acceptable because George was directly involved with his own care c) No, because George accessed his own medical record using his EMR login d) Yes, this is acceptable because George is cleared to work at the hospital and has worked many times with the physician - ANSWER-No, because George accessed his own medical record using his EMR login If a Pt signs a waiver giving you permission to capture photo of their unique rash, would you be committing a HIPAA violation by using your cell phone to capture the photo? Select the best option. a) Yes, because the phone is not an approved hospital device b) Yes, because the phone is not encrypted c) Yes, because the phone is not an approved hospital device and it is not encrypted d) No, because the phone is not an approved hospital device e) No, because the phone is not encrypted f) No, because the phone is not an approved hospital device and it is not encrypted - ANSWER-Yes, because the phone is not an approved hospital device and it is not encrypted Which of the following would NOT be an example of PHI? Select all that apply. • Photos of an injury • Headshot • Driver's license number • Diagnosis • Email address • The name of the medical clinic that a Pt receives care at • Results of pending studies • Type of insurance • Fax number • Home phone number • Cell phone number • Home address • Social security number • MRN • DOB • None of the above - ANSWER-• None of the above (All are PHI) A 43 y/o male presents to the ED with vomiting that began 5 hours ago. He has a Hx of Type II DM and is s/p right BKA. On objective evaluation, it is found that he is hyperglycemic and has elevated ketones and so he will be admitted for DKA. Match the details to the correct section of the chart. 1) PSHx 2) ED Course 3) Onset 4) Disposition 5) PMHx 6) CC 7) Diagnosis Choices: DKA • Right BKA • Vomiting • 5 hours ago • Admit • Type II DM • Hyperglycemia & elevated ketones - ANSWER-1) Right BKA