SCRIBE FINAL EXAM STUDY GUIDE
QUESTIONS AND ANSWERS
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
QUESTIONS AND ANSWERS
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
