ScribeAmerica OP Final Exam Questions And Answers.
1. : History of Present Illness
2. Physician tells you patient has bibasilar crackles on exam . Wh ich body
system: Respiratory
3. Why is it important to document tears on pets&adult pts: Indicates pt is
hydrated
4. When should the word "lethargy" be documented on the chart?: Only when
the physician explicitly tells you to do so
5. Contradictory Phrase: Eyes: PERRL pupils non reactive with anisocoria Nuero:
Cranial nerves grossly intact
6. Positive straight leg = herniated disc which body system: Back
7. Murphy's sign where?: Abdomen
8. Can you document both "Clear breath sounds bilaterally" and "rhonchi in
the right base"? Why or why not?: No, because they contradict each other
9. What surgical procedure should be performed to diagnose CAD: cardiac
catheterization
10. W/ information should be included in the plan selection when document-
ing: prescription meds & diagnostic testing, follow up pcp , follow up with specialist,
life style recommendations & preventative care instructions
11. Which ROS would include menorrhagia (strong period): Genitourinary
12. Difficulty breathing: dyspnea
13. PT got her uterus removed what's her PSHX?: Hysterectomy
14. Bacterial Lung Infection: PNA
15. Which of the following would be valid complaints for HTN: CHF, MI, CRF,
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, ScribeAmerica OP Final Exam Questions And Answers.
Impaired vision, CAD
16. Codes included on every super bill: E&M , ICD codes
17. HPI Element content: Information regarding prior episodes, information regard-
ing prior evaluations, information regarding risk factors
18. 3 details that should summarized for results in the assessment section: -
Name of test, result of test, reason why test was ordered
19. Pt underwent surgery to have her an ovary and fallopian tube removed w/
PSHX would you record ?: Salpingo-oophorectomy
20. E&M code of 99215 w/ does it mean: LOS 5, Established PT
21. Single ovary removed: oophorectomy
22. 45yr old male presents w/ constant ripping, tearing pain to central chest
straight to his back w/ nausea began 1hr ago w/ accompanying dyspnea and
diaphoresis - what elements are missing: Severity, modifying factors, relevant
context
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1. : History of Present Illness
2. Physician tells you patient has bibasilar crackles on exam . Wh ich body
system: Respiratory
3. Why is it important to document tears on pets&adult pts: Indicates pt is
hydrated
4. When should the word "lethargy" be documented on the chart?: Only when
the physician explicitly tells you to do so
5. Contradictory Phrase: Eyes: PERRL pupils non reactive with anisocoria Nuero:
Cranial nerves grossly intact
6. Positive straight leg = herniated disc which body system: Back
7. Murphy's sign where?: Abdomen
8. Can you document both "Clear breath sounds bilaterally" and "rhonchi in
the right base"? Why or why not?: No, because they contradict each other
9. What surgical procedure should be performed to diagnose CAD: cardiac
catheterization
10. W/ information should be included in the plan selection when document-
ing: prescription meds & diagnostic testing, follow up pcp , follow up with specialist,
life style recommendations & preventative care instructions
11. Which ROS would include menorrhagia (strong period): Genitourinary
12. Difficulty breathing: dyspnea
13. PT got her uterus removed what's her PSHX?: Hysterectomy
14. Bacterial Lung Infection: PNA
15. Which of the following would be valid complaints for HTN: CHF, MI, CRF,
1/ 7
, ScribeAmerica OP Final Exam Questions And Answers.
Impaired vision, CAD
16. Codes included on every super bill: E&M , ICD codes
17. HPI Element content: Information regarding prior episodes, information regard-
ing prior evaluations, information regarding risk factors
18. 3 details that should summarized for results in the assessment section: -
Name of test, result of test, reason why test was ordered
19. Pt underwent surgery to have her an ovary and fallopian tube removed w/
PSHX would you record ?: Salpingo-oophorectomy
20. E&M code of 99215 w/ does it mean: LOS 5, Established PT
21. Single ovary removed: oophorectomy
22. 45yr old male presents w/ constant ripping, tearing pain to central chest
straight to his back w/ nausea began 1hr ago w/ accompanying dyspnea and
diaphoresis - what elements are missing: Severity, modifying factors, relevant
context
2/ 7
