Scribe practice for test

What and where should you write when the HPI cannot be obtained? - Answer- write it in HPI, PFSH, ROS, and EXAM Circle limited by pt condition, impairment, AMS or urgency Is the info in the HPI subjective or objective? - Answer- subjective does chronological order matter when writing a HPI? - Answer- yes If your provider asks a specific question while obtaining the HPI, is it pertinent to document the answer? Explain - Answer- yes because the provider is focusing on a specific area. The questions they ask are relevant to the pt's present illness or injury. The pt's answers will provide pertinent positives and negatives that can help the provider determine a diagnosis Is the HPI written in third person? - Answer- yes If you are missing elements in the HPI is it okay to make things up? - Answer- NEVER In your own words explain what ROS is? - Answer- Is the review of the systems that is obtained from the HCP's interview with the patient. It will include any of the signs or symptoms that pt may or may not be experiencing Is ROS subjective or objective? - Answer- subjective Name 6 body systems found in ROS? - Answer- Neuro HENT Eye CV GU Psych Const. Neck Resp ABD/GI Musc Skin Lymph How many billing levels are there? - Answer- 5 Which number is the highest acuity? - Answer- 5