ScribeAmerica Outpatient Final: Practice Questions and correct
answers.
What will the scribe document for the outpatient visit? - Important notes for past medical records
History and Physical
Laboratory and radiology results
Physician Interpretation of XRs and EKGs
Assessment and Plan
Who is the first person to speak with the patient after he/she is placed in the room? - Nurse or MA
What are the meaningful use requirements the nurse or MA will obtain? - Vital Signs (BP, RR, HR, T),
Chief Complaint, Height, Weight, BMI, Smoking Status
What does H&P abbreviate and who performs this evaluation? - History and Physical, physician
Is a differential diagnosis necessary for a health maintenance visit? - No, only for a diagnostic visit
What information will be included in the patient's plan? - Specialist follow-up, instructions for
lifestyle and preventative care, routine follow-up
The CBC shows anemia - Results
The EKG shows NSR - Results
The pt came to the clinic for chest pain - HPI/ROS
The pt also stubbed his toe last week - HPI/ROS
https://www.stuvia.com/
, The pt is in no acute distress - Physical Exam
The pt has suffered from HTN for many years - PMHx
Thee is tenderness of the RUQ - PE
The pt's mother has heart disease - FHX
The diagnosis is upper respiratory infection - Assessment
The pt will be prescribed penicillin today - Plan
What age would a family member's cardiac disease indicate an increased risk for similar heart
disease in the pt? - <55 y/o
What are three common general FHx your physician may ask about? - HTN, CA, DM
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - Yes
Why must smoking status be documented on every patient 13 years and older? - Meaningful use
requirements
HIPPA Rule 1 - If a patient is not assigned to your doctor, do not touch the chart
HIPAA Rule 2 - There is always someone watching
HIPAA Rule 3 - Never share your username or password
HIPAA Rule 4 - Your job does not belong on social media
HIPAA Rule 5 - Ask yourself "Do I need to access this for my job?"
https://www.stuvia.com/
answers.
What will the scribe document for the outpatient visit? - Important notes for past medical records
History and Physical
Laboratory and radiology results
Physician Interpretation of XRs and EKGs
Assessment and Plan
Who is the first person to speak with the patient after he/she is placed in the room? - Nurse or MA
What are the meaningful use requirements the nurse or MA will obtain? - Vital Signs (BP, RR, HR, T),
Chief Complaint, Height, Weight, BMI, Smoking Status
What does H&P abbreviate and who performs this evaluation? - History and Physical, physician
Is a differential diagnosis necessary for a health maintenance visit? - No, only for a diagnostic visit
What information will be included in the patient's plan? - Specialist follow-up, instructions for
lifestyle and preventative care, routine follow-up
The CBC shows anemia - Results
The EKG shows NSR - Results
The pt came to the clinic for chest pain - HPI/ROS
The pt also stubbed his toe last week - HPI/ROS
https://www.stuvia.com/
, The pt is in no acute distress - Physical Exam
The pt has suffered from HTN for many years - PMHx
Thee is tenderness of the RUQ - PE
The pt's mother has heart disease - FHX
The diagnosis is upper respiratory infection - Assessment
The pt will be prescribed penicillin today - Plan
What age would a family member's cardiac disease indicate an increased risk for similar heart
disease in the pt? - <55 y/o
What are three common general FHx your physician may ask about? - HTN, CA, DM
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - Yes
Why must smoking status be documented on every patient 13 years and older? - Meaningful use
requirements
HIPPA Rule 1 - If a patient is not assigned to your doctor, do not touch the chart
HIPAA Rule 2 - There is always someone watching
HIPAA Rule 3 - Never share your username or password
HIPAA Rule 4 - Your job does not belong on social media
HIPAA Rule 5 - Ask yourself "Do I need to access this for my job?"
https://www.stuvia.com/
