ScribeAmerica OP Final Exam UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS
History of Present Illness
, Physician tells you patient has bibasilar crackles on exam Respiratory
. Which body system
Why is it important to document tears on pets&adult pts Indicates pt is hydrated
When should the word "lethargy" be documented on the Only when the physician explicitly tells you to do so
chart?
Contradictory Phrase Eyes: PERRL pupils non reactive with anisocoria Nuero: Cranial nerves grossly
intact
Positive straight leg = herniated disc which body system Back
Murphy's sign where? Abdomen
Can you document both "Clear breath sounds bilaterally" No, because they contradict each other
and "rhonchi in the right base"? Why or why not?
What surgical procedure should be performed to cardiac catheterization
diagnose CAD
W/ information should be included in the plan selection prescription meds & diagnostic testing, follow up pcp , follow up with specialist,
when documenting life style recommendations & preventative care instructions
Which ROS would include menorrhagia (strong period) Genitourinary
Difficulty breathing dyspnea
PT got her uterus removed what's her PSHX? Hysterectomy
Bacterial Lung Infection PNA
Which of the following would be valid complaints for CHF, MI, CRF, Impaired vision, CAD
HTN
Codes included on every super bill E&M , ICD codes
HPI Element content Information regarding prior episodes, information regarding prior evaluations,
information regarding risk factors
3 details that should summarized for results in the Name of test, result of test, reason why test was ordered
assessment section
Pt underwent surgery to have her an ovary and fallopian Salpingo-oophorectomy
tube removed w/ PSHX would you record ?
ANSWERS
History of Present Illness
, Physician tells you patient has bibasilar crackles on exam Respiratory
. Which body system
Why is it important to document tears on pets&adult pts Indicates pt is hydrated
When should the word "lethargy" be documented on the Only when the physician explicitly tells you to do so
chart?
Contradictory Phrase Eyes: PERRL pupils non reactive with anisocoria Nuero: Cranial nerves grossly
intact
Positive straight leg = herniated disc which body system Back
Murphy's sign where? Abdomen
Can you document both "Clear breath sounds bilaterally" No, because they contradict each other
and "rhonchi in the right base"? Why or why not?
What surgical procedure should be performed to cardiac catheterization
diagnose CAD
W/ information should be included in the plan selection prescription meds & diagnostic testing, follow up pcp , follow up with specialist,
when documenting life style recommendations & preventative care instructions
Which ROS would include menorrhagia (strong period) Genitourinary
Difficulty breathing dyspnea
PT got her uterus removed what's her PSHX? Hysterectomy
Bacterial Lung Infection PNA
Which of the following would be valid complaints for CHF, MI, CRF, Impaired vision, CAD
HTN
Codes included on every super bill E&M , ICD codes
HPI Element content Information regarding prior episodes, information regarding prior evaluations,
information regarding risk factors
3 details that should summarized for results in the Name of test, result of test, reason why test was ordered
assessment section
Pt underwent surgery to have her an ovary and fallopian Salpingo-oophorectomy
tube removed w/ PSHX would you record ?
