SCRIBE AMERICA COMPLETE QUESTIONS
AND SOLUTIONS TESTED ANSWERS
◉ T/F. A family friend was recently evaluated for IDDM and lost
his paperwork and does not know what medications he should be
taking at home. He asks you to look up his medical record when
you go to your shift today, giving you verbal permission to access
his information. In this scenario, it is justifiable for you to use your
EMR login to look up the important patient information.
Answer: False
◉ A patient is s/p angioplasty with stent and quadruple cardiac
bypass. What chronic condition should be included in their
diagnosis today? Expand the abbreviation. (Remember do not
include spaces before or after your answer.)
Answer: Coronary artery disease
◉ A patient states that he has been having abdominal pain for the
last three days, and it varies between mild and severe. Which of
the following would best describe the Timing?
Answer: Waxing and waning
◉ The patient reports a tenderness in their right upper abdomen
that began 2 weeks ago. Based on that information, do you
document RUQ tenderness under the physical exam?
Answer: No
,◉ What condition correctly describes "heart attack"? (Use the
abbreviated form of the condition)
Answer: MI
◉ A patient reportedly had their tonsils removed as a child. What
PSHx would you record into the chart? (Remember, do not include
any spaces before or after the term/phrase.)
Answer: Tonsillectomy
◉ What is the medical term for an elevated heart rate (over 100
beats per minute)?
Answer: tachycardia
◉ Identify what details are included in the following Assessment.
(Select all that apply.)
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in
acute exacerbation today. He reports decreased urinary output
that has progressively worsened since onset 5 days ago.
Creatinine and BUN elevated and worsening compared to last visit
3 weeks ago. Patient recommended emergency dialysis today and
warned that he may be at risk for death and other complications if
he does not seek further urgent medical attention. Patient
understands and agrees to be transferred to the ED."
Answer: Age and sex
PHx, if relevant
Diagnosis
, Results
HPI
Prognosis/Plan
◉ T/F. All symptoms documented in the ROS are also documented
in the HPI.
Answer: False
◉ What is the medical term for "open heart surgery"? HINT:
expand the abbreviation. (Remember: do not include any spaces
before or after the term/phrase)
Answer: coronary artery bypass graft
◉ Identify which of these PE systems contains contradictory
findings:
Answer: Respiratory: No respiratory distress, tachypnea, lungs
are clear to auscultation bilaterally
◉ If a patient signs a waiver giving you permission to capture
photo of their unique rash, would you be committing a HIPAA
violation by using your cellphone to capture the photo? (Select the
best option.)
Answer: Yes because the phone is not an approved hospital device
and it is not encrypted.
AND SOLUTIONS TESTED ANSWERS
◉ T/F. A family friend was recently evaluated for IDDM and lost
his paperwork and does not know what medications he should be
taking at home. He asks you to look up his medical record when
you go to your shift today, giving you verbal permission to access
his information. In this scenario, it is justifiable for you to use your
EMR login to look up the important patient information.
Answer: False
◉ A patient is s/p angioplasty with stent and quadruple cardiac
bypass. What chronic condition should be included in their
diagnosis today? Expand the abbreviation. (Remember do not
include spaces before or after your answer.)
Answer: Coronary artery disease
◉ A patient states that he has been having abdominal pain for the
last three days, and it varies between mild and severe. Which of
the following would best describe the Timing?
Answer: Waxing and waning
◉ The patient reports a tenderness in their right upper abdomen
that began 2 weeks ago. Based on that information, do you
document RUQ tenderness under the physical exam?
Answer: No
,◉ What condition correctly describes "heart attack"? (Use the
abbreviated form of the condition)
Answer: MI
◉ A patient reportedly had their tonsils removed as a child. What
PSHx would you record into the chart? (Remember, do not include
any spaces before or after the term/phrase.)
Answer: Tonsillectomy
◉ What is the medical term for an elevated heart rate (over 100
beats per minute)?
Answer: tachycardia
◉ Identify what details are included in the following Assessment.
(Select all that apply.)
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in
acute exacerbation today. He reports decreased urinary output
that has progressively worsened since onset 5 days ago.
Creatinine and BUN elevated and worsening compared to last visit
3 weeks ago. Patient recommended emergency dialysis today and
warned that he may be at risk for death and other complications if
he does not seek further urgent medical attention. Patient
understands and agrees to be transferred to the ED."
Answer: Age and sex
PHx, if relevant
Diagnosis
, Results
HPI
Prognosis/Plan
◉ T/F. All symptoms documented in the ROS are also documented
in the HPI.
Answer: False
◉ What is the medical term for "open heart surgery"? HINT:
expand the abbreviation. (Remember: do not include any spaces
before or after the term/phrase)
Answer: coronary artery bypass graft
◉ Identify which of these PE systems contains contradictory
findings:
Answer: Respiratory: No respiratory distress, tachypnea, lungs
are clear to auscultation bilaterally
◉ If a patient signs a waiver giving you permission to capture
photo of their unique rash, would you be committing a HIPAA
violation by using your cellphone to capture the photo? (Select the
best option.)
Answer: Yes because the phone is not an approved hospital device
and it is not encrypted.
