A patient comes in visibly short of breath. How is the Respiratory Rate (RR)
calculated?
Allow patient to rest for a while and then begin counting breaths once they are no
longer short of breath for 60 seconds
Calculate the number of chest rises and falls in 15 seconds and multiply that
number by 4 to get the RR for 1 minute
Calculate the RR by dividing the Heart Rate by 2 at a resting position
Calculation is automatically done by the Pulse Oximeter
Call the Provider to count the RR accurately and then chart that reading in the
EHR Ans✓✓✓ Calculate the number of chest rises and falls in 15 seconds and
multiply that number by 4 to get the RR for 1 minute
A patient visits CityMD for the first time and complains of just a cough(simple).
Which E&M code would most likely apply to this case?
99203
99213
99214
99202 Ans✓✓✓ 99203
A patient you are charting for requires a STAT CBC, this lab order can be found in:
Orders Section of Assessment & Plan
Order Sets Section of Assessment & Plan
Procedure Documentation
Physical Exam Ans✓✓✓ Order Sets Section of Assessment & Plan
, A Scribe Statement and E&M Code are necessary for every patient's chart.
True
False Ans✓✓✓ False
Clicking the door icon for every patient that is in "Done with exam" status is
mandatory.
True
False Ans✓✓✓ True
How do you put a X ray order in/find x ray? Ans✓✓✓ 1. In Assessment & Plan
2. Type xray body part
3. Click orders
How do you put in a referral/ find referral? Ans✓✓✓ 1. Assessment & Plan
2. List
3. Specialist (Cardiology, Urology)
If multiple HPIs are present, it is necessary to address chronic
comorbidities/conditions listed in the patient's chart underneath each HPI
section.
True
False Ans✓✓✓ False
In what scenario(s) would you change the patient location to "CT/US/MRI or
Referral (STAT/LIST)"? A- Chest X-Ray B- Stat Dermatology Referral C- List ENT
Referral D- Urgent Cardiology Referral E- STAT CT Scan of Abdomen & Pelvis