Scribe America OP Final Exam with 100% Correct Answers 2023(AUGUST QTR)

What medical term describes the surgical removal of the gallbladder? - Correct answer- cholecystectomy 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 answer- Established 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 place -To require equal access, opportunity, and affordability for health insurance plans by screening patient health information What medical term would describe a patient with a history of infection or inflammation of the liver? - Correct answer-Hepatitis For correct billing and reimbursement to go through, a counseling note requires documentation of the following: - Correct answer-- Total time with the patient - Percentage of time spent counseling 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? - Correct answer-Chronologic structure Which of the following would be valid complications for CAD? - Correct answer-MI * 57 year old male patient presented with RLQ abdominal pain, which began 5 days ago. He states that he was mowing the lawn when the pain began. Patient reports he took OTC Tylenol yesterday without relief. There has been no nausea, vomiting or diarrhea. - Correct answer-Yes, the HPI meets Level 4 billing criteria. What are the possible consequences of a HIPAA violation? (select all that apply) - Correct answer-- Termination -Monetary fines to you and the hospital - Prison time -Lawsuit against you and the hospital -Violator is blacklisted from medical programs like Medical, PA, or NP school - Scribe program cancellation 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 ". - Correct answer-Health Insurance Portability and Accountability Act What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT: two words. Expand abbreviations. - Correct answer-diabetes mellitus 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? - Correct answer-Yes, because the fever started soon after the cough * Which of the following would be documented in the Objective section of the SOAP note? (select all that apply.) - Correct answer-- Orders - Interpretations/results - Treatments (that may involve medication or procedures) - Physical exam