Scribe America OP Final Exam with 100% Correct Answers 2023

ScribeAmerica OP Final Exam with 100% Correct Answers 2023 What medical term describes the surgical removal of the gallbladder? - Correct answercholecystectomy What does "PHI" stand for? Expand the abbreviation. - Correct answer-Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - Correct answer-False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Correct answer-craniotomy A patient's PCP is on vacation. The patient is scheduled to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP before. Is this patient considered a new patient or an established patient? - Correct answerEstablished A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physician discusses 4-5 different back stretching exercises that the patient can perform every morning and before doing any heavy lifting. The discussion only takes 10 minutes of a 15 minute Established Patient visit. Would your physician be able to bill counseling time on this patient? - Correct answer-Yes What medical term would best describe "the likely course or outcome of a disease"? - Correct answer-Prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have"? - Correct answer-PHx You are writing an HPI for a patient who presented for hyperlipidemia management. In the middle of the visit, your patient also reports having recently experienced urinary symptoms. Which HPI structure would be the best to use in this scenario? - Correct answer-Multiple complaints structure Which of the following is NOT a purpose of HITECH? - Correct answer-- To require patient accountability in paying for their health care visit - To require government accountability on health insurance plans available in the market place -To require equal access, opportunity, and affordability for health insurance plans by screening patient health information What medical term would describe a patient with a history of infection or inflammation of the liver? - Correct answer-Hepatitis For correct billing and reimbursement to go through, a counseling note requires documentation of the following: - Correct answer-- Total time with the patient - Percentage of time spent counseling You are writing an HPI for a very complex patient who has had multiple recent hospital admissions for lung cancer. Which HPI structure would be the best to use in this scenario? - Correct answer-Chronologic structure Which of the following would be valid complications for CAD? - Correct answer-MI * 57 year old male patient presented with RLQ abdominal pain, which began 5 days ago. He states that he was mowing the lawn when the pain began. Patient reports he took OTC Tylenol yesterday without relief. There has been no nausea, vomiting or diarrhea. - Correct answer-Yes, the HPI meets Level 4 billing criteria. What are the possible consequences of a HIPAA violation? (select all that apply) - Correct 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 What does HIPAA stand for? Expand the abbreviation. Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ". - Correct answer-Health Insurance Portability and Accountability Act What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT: two words. Expand abbreviations. - Correct answer-diabetes mellitus A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not? - Correct answer-Yes, because the fever started soon after the cough * Which of the following would be documented in the Objective section of the SOAP note? (select all that apply.) - Correct answer-- Orders - Interpretations/results - Treatments (that may involve medication or procedures) - Physical exam HIPAA is a set of laws designed to _______. (Select the best option.) - Correct answermaintain patient privacy and confidentiality What condition correctly describes "blood clot in the lungs"? (Use the abbreviation form of the condition) - Correct answer-PE * MACRA - Correct answer-government healthcare initiative that focuses on quality of care to improve patient outcomes. * MIPS - Correct answer-system of payment in which government funding is released if specific quality measures are tracked Quality Measures - Correct answer-site specific health criteria that are tracked High Risk - Correct answerModerate Risk - Correct answerLow Risk - Correct answerWhat chronic condition would require diagnosis through a lipid panel? Use the abbreviation form. - Correct answer-HLD * Which of the following are considered non-reimbursable chief complaints? - Correct answer-- Follow-up - Check-up - Medication refill - Lab results CP - Correct answer-chest pain T/F. A family friend was recently evaluated for IDDM and lost his paperwork and does not know what medications he should be taking at home. He asks you to look up his medical record when you go to your shift today, giving you verbal permission to access his information. In this scenario, it is justifiable for you to use your EMR login to look up the important patient information. - Correct answer-F What condition correctly describes "dangerous infection of the appendix"? (Do not use abbreviations. - Correct answer-appendicitis An elderly male patient has a history of an enlarged prostate. What PMHx would you record into the chart? - Correct answer-BPH * A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic condition should be included in their diagnosis today? Expand the abbreviation. - Correct answer-Coronary Artery Disease A patient states that he has been having abdominal pain for the last three days, and it varies between mild and severe. Which of the following would best describe the Timing? - Correct answer-waxing and waning The patient reports a tenderness in their right upper abdomen that began 2 weeks ago. Based on that information, do you document RUQ tenderness under the physical exam? - Correct answer-No * What condition correctly describes "heart attack"? (Use the abbreviated form of the condition) - Correct answer-MI * An elderly male patient has a history of an enlarged prostate and has undergone surgery to treat his condition. What PSHx would you record into the chart? Use the abbreviation form. - Correct answer-TURP What medical term is used to describe the symptom of a patient's heart beating rapidly, irregularly, or forcibly? - Correct answer-palpitations * "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED." - Correct answer-- Age and Sex - PHx, if relevant - Diagnosis - Results - HPI ( first two sentences) - Prognosis/Plan T/F. All symptoms documented in the ROS are also documented in the HPI. - Correct answer-F What is the medical term for "open heart surgery"? HINT: expand the abbreviation. - Correct answer-Coronary Artery Bypass Graft Identify which of these PE systems contains contradictory findings: - Correct answerRespiratory: No respiratory distress, tachypnea, lungs are clear to auscultation bilaterally If a patient signs a waiver giving you permission to capture photo of their unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo? (Select the best option.) - Correct answer-Yes because the phone is not an approved hospital device and it is not encrypted. What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"? HINT: Use the abbreviation form of the condition. - Correct answer-CAD An elderly female patient has a history of brittle bone disease and is at risk for developing bone fractures. What PMHx would you record into the chart? - Correct answer-osteoporosis What medical term is used to describe the physician examining the patient by touch? - Correct answer-palpation Organize the parts of the chart in order from top (1) to bottom (7). - Correct answer-1. HPI 2. ROS 3. PHx 4. PE 5. Orders/Results 6. Assessment 7. Plan What ROS system would include dysphagia, the medical term for difficult or painful swallowing? - Correct answer-ENT T/F. The ROS does not contain the CC and its associated symptoms because they are already listed in the HPI. - Correct answer-F (bc anything in hpi will be in ros) 48 - Correct answer- * A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? (HINT: Expand the medical abbreviation.) - Correct answer-coronary artery bypass graft A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer) - Correct answer-5,2,2 What body system would the exam finding PERRL be documented in? - Correct answer-Eyes T/F. It is acceptable to look up your own medical information while working in the clinic. - Correct answer-F * What condition correctly describes "mini-stroke"? (Use the abbreviation form of the condition.) - Correct answer-TIA A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart? (HINT: one word only.) - Correct answer-angioplasty Which of the following are considered to be cardiac risk factors for CP patients? (select all that apply) - Correct answer-- HTN - HLD - Family hx of CAD 55 y/o - PSHx of CABG, angioplasty, and stent - DM (can cause severe bleeding. Have to know DM for my clinic) - CAD - tobacco use What is the medical term for "slow heart rate"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase) - Correct answerbradycaridia What medical term can be used to describe "having multiple chronic conditions"? - Correct answer-comorbidities A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (HINT: two words) - Correct answer-partial lobectomy What can scribes in the clinic do to help accomplish MACRA and MIPS goals? - Correct answer-- Document quality measures that are met by the physician during the visit. - Prompt the provider to perform a quality measure. - Use a trackingsheet to keep a track of patients that meet criteria for quality measures. Determine which structure best fits the following Assessment. "Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no visible signs of tonsilar exudate. Rapid strep negative." - Correct answer-Brief summary You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "The pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam? - Correct answer-- wrist 2+ radial pulse - top of foot 2+ DP pulse - neck 2+ carotid pulse - back of foot 2+ PT pulse