Scribe Final Exam Questions and Answers

Scribe Final Exam Questions and Answers What ROS system would include dysphagia, the medical term for difficult or painful swallowing? - Answer-Gastrointestinal ENT T/F. The ROS does not contain the CC and its associated symptoms because they are already listed in the HPI. - Answer-T T/F. Resolved problems may be deleted from the problem list. - Answer-F A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? - 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) - Answer-5,2,2 T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they are included in the Problem List section. - Answer-F T/F. It is acceptable to look up your own medical information while working in the clinic. - Answer-F What condition correctly describes "mini-stroke"? (abbrev) - Answer-TIA A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart? - Answer-Angioplasty Which of the following are considered to be cardiac risk factors for CP patients? (select all that apply.) - Answer-PSHx of CABG, angioplasty and stent HLD DM HTN CAD FHx of CAD <55 y/o tobacco use What is the medical term for "slow heart rate"? - Answer-Bradycardia What medical term can be used to describe "having multiple chronic conditions"? - Answer-Comorbidity A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (Two words) - Answer-partial lobectomy What can scribes in the clinic do to help accomplish MACRA and MIPS goals? - Answer-Document quality measures that are met by the physician during the visit. Prompt the provider to perform a quality measure. Use a tracking sheet 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." - Answer-Brief summary Which details are optional to include in a patient problem list? - Answer-Resolved date Notes Onset date What condition correctly describes "A blood clot in the extremities"? (abbrev) - Answer-DVT A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart? - Answer-mastectomy Match the following description with the corresponding code. - Answer-IDC code = diagnosis E&M = reimbursement HCC = risk Determine which structure best fits the following Assessment. "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." - Answer-comprehensive summary What FHx/SHx information is usually asked for pediatric patients? (Select all that apply.) - Answer-Second hand smoke exposure immunization status