SCRIBE FINAL EXAM GUIDE Q&A
What are two signs of respiratory distress in a pediatric patient? - Answer-nasal flaring
stridor
What are 2 items besides the diagnosis that may be documented in the assessment? -
Answer-lab results
summary of PE/HPI
When summarizing test results, which items should be included? - Answer-date of the
test
result of the test
reason for the test
Is the plan typically formatted as a paragraph or a bullet-pointed list? - Answer-bullet-
pointed list
T/F : Each diagnosis should be followed-up with at least one line-item in the plan. -
Answer-T
The last bullet in the plan should always be - Answer-timeline for follow-up
Alice has her first orthopedic visit with Dr. Smith whose partner, Dr. Roy, saw Alice 18
months ago for a wrist sprain. Is Alice considered a new patient during her appointment
with Dr. Smith? - Answer-no
Which type of patients (new or established) typically have longer and more detailed
visits? - Answer-new
Do new patients require more or less documentation than established patients in order
to bill for the same level? - Answer-more documentation
Fix the following chief complaints to make them billable:
Ex: Follow up: The patient is following up after their recent discharge from the hospital.
1. results
2. refill
3. check-up - Answer-1. discuss treatment options based on results.
2. evaluation of medication management.
3. maintenance visit
What can scribes do to help accomplish MACRA and MIPS? - Answer-- document
quality measures.
- prompt the provider to perform a quality measures.
- use a tracking sheet to keep a track of patients that meet criteria for quality measures.
, A new patient is someone who - Answer-has had no care with any member of the billing
physicians specialty or practice group within 3 years.
An established patient is someone who - Answer-has been seen in the clinic (with any
provider) within the last 3 years.
Which are considered cardiac risk factors for patients with chest pain? - Answer-HTN
HLD
FHx of CAD <55 y/o
PSHX of CABG
Who is the intended audience of an HPI? List someone other than the physician. -
Answer-medical records and billing specialist / insurance company
What is the main difference between the HPI and ROS? - Answer-HPI is the story of
chief complaint
ROS is a checklist of symptoms from all body systems
Note: not everything in the ROS goes in the HPI but everything in the HPI goes in the
ROS.
A patient states she had a productive cough for 4 days and then developed a fever. Is
the fever pertinent information? Why or why not? - Answer-Yes, the fever is a symptom
that the body is fighting an infection and a result of her cough.
A patient comes to the doctor complaining of back pain for two days. He notes that he
has also had a runny nose for 1 week. Would you document the "runny nose" in the HPI
or ROS? Why? - Answer-ROS
a runny nose is not pertinent to back pain, which is his CC
What elements/descriptors should you include in the HPI when describing a patient's
pain? - Answer-severity (mild, moderate, severe or 0-10)
Name 5 body systems (for the physical exam) the physician can examine simply by
observing (not touching) the patient: - Answer-eyes
integumentary/skin
neurological
psychiatric
constitutional
Subjective information includes - Answer-Chief complaint, HPI, ROS
HPI elements - Answer-Onset - when it started
Timing - has it been constant or intermittent
Location - where is it
What are two signs of respiratory distress in a pediatric patient? - Answer-nasal flaring
stridor
What are 2 items besides the diagnosis that may be documented in the assessment? -
Answer-lab results
summary of PE/HPI
When summarizing test results, which items should be included? - Answer-date of the
test
result of the test
reason for the test
Is the plan typically formatted as a paragraph or a bullet-pointed list? - Answer-bullet-
pointed list
T/F : Each diagnosis should be followed-up with at least one line-item in the plan. -
Answer-T
The last bullet in the plan should always be - Answer-timeline for follow-up
Alice has her first orthopedic visit with Dr. Smith whose partner, Dr. Roy, saw Alice 18
months ago for a wrist sprain. Is Alice considered a new patient during her appointment
with Dr. Smith? - Answer-no
Which type of patients (new or established) typically have longer and more detailed
visits? - Answer-new
Do new patients require more or less documentation than established patients in order
to bill for the same level? - Answer-more documentation
Fix the following chief complaints to make them billable:
Ex: Follow up: The patient is following up after their recent discharge from the hospital.
1. results
2. refill
3. check-up - Answer-1. discuss treatment options based on results.
2. evaluation of medication management.
3. maintenance visit
What can scribes do to help accomplish MACRA and MIPS? - Answer-- document
quality measures.
- prompt the provider to perform a quality measures.
- use a tracking sheet to keep a track of patients that meet criteria for quality measures.
, A new patient is someone who - Answer-has had no care with any member of the billing
physicians specialty or practice group within 3 years.
An established patient is someone who - Answer-has been seen in the clinic (with any
provider) within the last 3 years.
Which are considered cardiac risk factors for patients with chest pain? - Answer-HTN
HLD
FHx of CAD <55 y/o
PSHX of CABG
Who is the intended audience of an HPI? List someone other than the physician. -
Answer-medical records and billing specialist / insurance company
What is the main difference between the HPI and ROS? - Answer-HPI is the story of
chief complaint
ROS is a checklist of symptoms from all body systems
Note: not everything in the ROS goes in the HPI but everything in the HPI goes in the
ROS.
A patient states she had a productive cough for 4 days and then developed a fever. Is
the fever pertinent information? Why or why not? - Answer-Yes, the fever is a symptom
that the body is fighting an infection and a result of her cough.
A patient comes to the doctor complaining of back pain for two days. He notes that he
has also had a runny nose for 1 week. Would you document the "runny nose" in the HPI
or ROS? Why? - Answer-ROS
a runny nose is not pertinent to back pain, which is his CC
What elements/descriptors should you include in the HPI when describing a patient's
pain? - Answer-severity (mild, moderate, severe or 0-10)
Name 5 body systems (for the physical exam) the physician can examine simply by
observing (not touching) the patient: - Answer-eyes
integumentary/skin
neurological
psychiatric
constitutional
Subjective information includes - Answer-Chief complaint, HPI, ROS
HPI elements - Answer-Onset - when it started
Timing - has it been constant or intermittent
Location - where is it
