Scribe America OP Final Exam with 100% Correct Answers

What medical term describes the surgical removal of the gallbladder? - Correct answercholecystectomy What does "PHI" stand for? Expand the abbreviation. - Correct answer-Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - Correct answer-False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Correct answer-craniotomy 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 the NP before. Is this patient considered a new patient or an established patient? - Correct answerEstablished A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physician discusses 4-5 different back stretching exercises that the patient can perform every morning and before 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? - Correct answer-Yes What medical term would best describe "the likely course or outcome of a disease"? - Correct answer-Prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have"? - Correct answer-PHx You are writing an HPI for a patient who presented 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? - Correct answer-Multiple complaints structure Which of the following is NOT a purpose of HITECH? - Correct answer-- To require patient accountability in paying for their health care visit - To require government accountability on health insurance plans available in the market