ScribeAmerica OP Final Exam Test with Answers | Graded A
* What medical term describes the surgical removal Which section of the chart should you document
of the gallbladder? - ANSWER - when you hear the following cue "what medical
cholecystectomy problems do you have"? - ANSWER -PHx
What does "PHI" stand for? Expand the abbreviation. You are writing an HPI for a patient who presented
- ANSWER -Protected Health Information for hyperlipidemia management. In the middle of the
visit, your patient also reports having recently
experienced urinary symptoms. Which HPI structure
would be the best to use in this scenario? -
T/F. Sharing information about a case with family is ANSWER -Multiple complaints structure
allowed, as long as you are scribing with the
physician assigned to the case. - ANSWER -
False
Which of the following is NOT a purpose of HITECH?
- ANSWER -- To require patient accountability
in paying for their health care visit
** A patient underwent brain surgery to treat bleeding - To require government accountability on health
in the brain from a stroke. What PSHx would you insurance plans available in the market place
record into the chart? - ANSWER -craniotomy -To require equal access, opportunity, and
affordability for health insurance plans by screening
patient health information
A patient's PCP is on vacation. The patient is
scheduled to see the NP who is covering for the PCP
during this time. The patient has never been seen by What medical term would describe a patient with a
the NP before. Is this patient considered a new history of infection or inflammation of the liver? -
patient or an established patient? - ANSWER - ANSWER -Hepatitis
Established
For correct billing and reimbursement to go through,
A patient is diagnosed with back strain caused by a counseling note requires documentation of the
heavy lifting. As part of the treatment, the physician following: - ANSWER -- Total time with the
discusses 4-5 different back stretching exercises that patient
the patient can perform every morning and before - Percentage of time spent counseling
doing any heavy lifting. The discussion only takes 10
minutes of a 15 minute Established Patient visit.
Would your physician be able to bill counseling time
on this patient? - ANSWER -Yes You are writing an HPI for a very complex patient
who has had multiple recent hospital admissions for
lung cancer. Which HPI structure would be the best
to use in this scenario? - ANSWER -
What medical term would best describe "the likely Chronologic structure
course or outcome of a disease"? - ANSWER -
Prognosis
Which of the following would be valid complications
for CAD? - ANSWER -MI
1/8
, ScribeAmerica OP Final Exam Test with Answers | Graded A
* Which of the following would be documented in the
Objective section of the SOAP note? (select all that
apply.) - ANSWER -- Orders
* 57 year old male patient presented with RLQ - Interpretations/results
abdominal pain, which began 5 days ago. He states - Treatments (that may involve medication or
that he was mowing the lawn when the pain began. procedures)
Patient reports he took OTC Tylenol yesterday - Physical exam
without relief. There has been no nausea, vomiting or
diarrhea. - ANSWER -Yes, the HPI meets Level
4 billing criteria.
HIPAA is a set of laws designed to _______. (Select
the best option.) - ANSWER -maintain patient
privacy and confidentiality
What are the possible consequences of a HIPAA
violation? (select all that apply) - ANSWER --
Termination
-Monetary fines to you and the hospital What condition correctly describes "blood clot in the
- Prison time lungs"? (Use the abbreviation form of the condition) -
-Lawsuit against you and the hospital ANSWER -PE
-Violator is blacklisted from medical programs like
Medical, PA, or NP school
- Scribe program cancellation
* MACRA - ANSWER -government healthcare
initiative that focuses on quality of care to improve
patient outcomes.
What does HIPAA stand for? Expand the
abbreviation. Remember, do not include any spaces
before or after the term/phrase. e.g. Correct way
"Good luck" vs incorrect " good luck ". - * MIPS - ANSWER -system of payment in which
ANSWER -Health Insurance Portability and government funding is released if specific quality
Accountability Act measures are tracked
What chronic condition would require diagnosis Quality Measures - ANSWER -site specific
through fasting blood glucose level or HbA1c? HINT:
health criteria that are tracked
two words. Expand abbreviations. - ANSWER -
diabetes mellitus
High Risk - ANSWER -
A patient states she has had a productive cough for 4
days, and yesterday she developed a fever. Would
her fever be considered an associated symptom for
her productive cough? Why or why not? - Moderate Risk - ANSWER -
ANSWER -Yes, because the fever started soon
after the cough
Low Risk - ANSWER -
2/8
* What medical term describes the surgical removal Which section of the chart should you document
of the gallbladder? - ANSWER - when you hear the following cue "what medical
cholecystectomy problems do you have"? - ANSWER -PHx
What does "PHI" stand for? Expand the abbreviation. You are writing an HPI for a patient who presented
- ANSWER -Protected Health Information for hyperlipidemia management. In the middle of the
visit, your patient also reports having recently
experienced urinary symptoms. Which HPI structure
would be the best to use in this scenario? -
T/F. Sharing information about a case with family is ANSWER -Multiple complaints structure
allowed, as long as you are scribing with the
physician assigned to the case. - ANSWER -
False
Which of the following is NOT a purpose of HITECH?
- ANSWER -- To require patient accountability
in paying for their health care visit
** A patient underwent brain surgery to treat bleeding - To require government accountability on health
in the brain from a stroke. What PSHx would you insurance plans available in the market place
record into the chart? - ANSWER -craniotomy -To require equal access, opportunity, and
affordability for health insurance plans by screening
patient health information
A patient's PCP is on vacation. The patient is
scheduled to see the NP who is covering for the PCP
during this time. The patient has never been seen by What medical term would describe a patient with a
the NP before. Is this patient considered a new history of infection or inflammation of the liver? -
patient or an established patient? - ANSWER - ANSWER -Hepatitis
Established
For correct billing and reimbursement to go through,
A patient is diagnosed with back strain caused by a counseling note requires documentation of the
heavy lifting. As part of the treatment, the physician following: - ANSWER -- Total time with the
discusses 4-5 different back stretching exercises that patient
the patient can perform every morning and before - Percentage of time spent counseling
doing any heavy lifting. The discussion only takes 10
minutes of a 15 minute Established Patient visit.
Would your physician be able to bill counseling time
on this patient? - ANSWER -Yes You are writing an HPI for a very complex patient
who has had multiple recent hospital admissions for
lung cancer. Which HPI structure would be the best
to use in this scenario? - ANSWER -
What medical term would best describe "the likely Chronologic structure
course or outcome of a disease"? - ANSWER -
Prognosis
Which of the following would be valid complications
for CAD? - ANSWER -MI
1/8
, ScribeAmerica OP Final Exam Test with Answers | Graded A
* Which of the following would be documented in the
Objective section of the SOAP note? (select all that
apply.) - ANSWER -- Orders
* 57 year old male patient presented with RLQ - Interpretations/results
abdominal pain, which began 5 days ago. He states - Treatments (that may involve medication or
that he was mowing the lawn when the pain began. procedures)
Patient reports he took OTC Tylenol yesterday - Physical exam
without relief. There has been no nausea, vomiting or
diarrhea. - ANSWER -Yes, the HPI meets Level
4 billing criteria.
HIPAA is a set of laws designed to _______. (Select
the best option.) - ANSWER -maintain patient
privacy and confidentiality
What are the possible consequences of a HIPAA
violation? (select all that apply) - ANSWER --
Termination
-Monetary fines to you and the hospital What condition correctly describes "blood clot in the
- Prison time lungs"? (Use the abbreviation form of the condition) -
-Lawsuit against you and the hospital ANSWER -PE
-Violator is blacklisted from medical programs like
Medical, PA, or NP school
- Scribe program cancellation
* MACRA - ANSWER -government healthcare
initiative that focuses on quality of care to improve
patient outcomes.
What does HIPAA stand for? Expand the
abbreviation. Remember, do not include any spaces
before or after the term/phrase. e.g. Correct way
"Good luck" vs incorrect " good luck ". - * MIPS - ANSWER -system of payment in which
ANSWER -Health Insurance Portability and government funding is released if specific quality
Accountability Act measures are tracked
What chronic condition would require diagnosis Quality Measures - ANSWER -site specific
through fasting blood glucose level or HbA1c? HINT:
health criteria that are tracked
two words. Expand abbreviations. - ANSWER -
diabetes mellitus
High Risk - ANSWER -
A patient states she has had a productive cough for 4
days, and yesterday she developed a fever. Would
her fever be considered an associated symptom for
her productive cough? Why or why not? - Moderate Risk - ANSWER -
ANSWER -Yes, because the fever started soon
after the cough
Low Risk - ANSWER -
2/8
