ScribeAmerica Outpatient Final Practice Questions & Answers Accurate 100% What will the scribe document for the outpatient visit? - ANSWERSImportant notes for past medical records History and Physical Laboratory and radiology results Physician Interpret

ScribeAmerica Outpatient Final Practice Questions & Answers Accurate 100% What will the scribe document for the outpatient visit? - ANSWERSImportant notes for past medical records History and Physical Laboratory and radiology results Physician Interpretation of XRs and EKGs Assessment and Plan Who is the first person to speak with the patient after he/she is placed in the room? - ANSWERSNurse or MA What are the meaningful use requirements the nurse or MA will obtain? - ANSWERSVital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status What does H&P abbreviate and who performs this evaluation? - ANSWERSHistory and Physical, physician Is a differential diagnosis necessary for a health maintenance visit? - ANSWERSNo, only for a diagnostic visit What information will be included in the patient's plan? - ANSWERSSpecialist follow-up, instructions for lifestyle and preventative care, routine follow-up The CBC shows anemia - ANSWERSResults The EKG shows NSR - ANSWERSResults The pt came to the clinic for chest pain - ANSWERSHPI/ROS The pt also stubbed his toe last week - ANSWERSHPI/ROS The pt is in no acute distress - ANSWERSPhysical Exam The pt has suffered from HTN for many years - ANSWERSPMHx Thee is tenderness of the RUQ - ANSWERSPE The pt's mother has heart disease - ANSWERSFHX The diagnosis is upper respiratory infection - ANSWERSAssessment The pt will be prescribed penicillin today - ANSWERSPlan What age would a family member's cardiac disease indicate an increased risk for similar heart disease in the pt? - ANSWERS55 y/o What are three common general FHx your physician may ask about? - ANSWERSHTN, CA, DM Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - ANSWERSYes Why must smoking status be documented on every patient 13 years and older? - ANSWERSMeaningful use requirements HIPPA Rule 1 - ANSWERSIf a patient is not assigned to your doctor, do not touch the chart HIPAA Rule 2 - ANSWERSThere is always someone watching HIPAA Rule 3 - ANSWERSNever share your username or password HIPAA Rule 4 - ANSWERSYour job does not belong on social media HIPAA Rule 5 - ANSWERSAsk yourself "Do I need to access this for my job?" HIPAA Rule 6 - ANSWERSDo not store any protected health information (PHI) on non-approved systems HIPAA Rule 7 - ANSWERSdo not access family, friend or own medical record HIPAA Rule 8 - ANSWERSNo cell phones or pictures What should you do before leaving your workstation for the cafeteria? - ANSWERSLog out What is the purpose of HIPAA? - ANSWERSIt is a body of laws designed to protect the private health information of patients across the country. What does PHI stand for? - ANSWERSProtected Health Information Name three items that are considered PHI - ANSWERSFirst or Last name, Date of birth, medical record number, the fact the patient was seen at the clinic What is the purpose of HITECH? - ANSWERSThe Health Information Technology for Economic and Clinical Health Act addresses the privacy and security issues related to electronic transmission of health information. PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption. Meaningful Use Objectives scribes help with - ANSWERS1. Up-to-date problem list 2. Demographics 3. Vital signs 4. Smoking status 5. Provide patient with a visit summary at check-out 6. Protect health information Who enforces meaningful use programs? - ANSWERSCenters for Medicare and Medicaid Services What are three goals of the meaningful use program? - ANSWERS1. Safely integrate technology into healthcare 2. Improve pt care coordination and track data trends 3. Empower patients through increased communication and transparency Give five in-house lab examples - ANSWERS1. Pregnancy test 2. INR check 3. Finger-stick blood glucose 4. Rapid strep test 5. Urine dip What is a V-Code? - ANSWERSA billing code for preventative care What does CPT stand for? - ANSWERSCurrent Procedural Terminology Name non-reimbursable complaints - ANSWERSfollow-up, check-up, lab results, medication refill True/False: A level 4 is a "comprehensive" E&M level? - ANSWERSTrue Why is it important to memorize the elements needed for a level 4? - ANSWERSTo accurately reflect care given and to document to a high level and avoid E&M level downgrading. How many HPI elements are needed for a new patient at level 4? - ANSWERS4 elements How many ROS elements are needed for established level 4? - ANSWERS2 elements True/False: Each diagnosis should be followed-up with at least one line-item in the plan? - ANSWERSTrue How is the plan formatted? - ANSWERSBullet points, numbers, or paragraph The last bullet point in the plan should always be? - ANSWERSthe follow-up Name three items you may include in a plan for Upper Respiratory Infection - ANSWERSAlternate Tylenol/Motrin for pain Push Fluids Off school for two days Return in 1 week, sooner if worse Name four items that can be included in a patient's plan: - ANSWERS1. Medication and treatment for each diagnosis 2. Prescriptions ordered today 3. Studies or tests ordered today 4. Follow-up with other healthcare professionals 5. Follow-up here for next appointment Name three items that can be included in a plan for a pt with DM? - ANSWERSStrictly follow metformin regimen as prescribed Continue adherence to diabetic diet If HbA1C has not improved next visit, will start insulin. Name three items that can be included in a plan for a pt with HTN? - ANSWERSContinue taking HCTZ as prescribed Continue BP log Will refill HCTZ today Follow-up in 3 months to check BP True/False: The scribe should only include results that are new since the last visit? - ANSWERSTrue What three items should you include when summarizing a test result? - ANSWERSName of test, result of test, and why the test was ordered Name four examples of lab results: - ANSWERSCBC, lipid panel, urinalysis, pregnancy Name four types of imaging studies: - ANSWERSx-ray, CT, MRI, ultrasound (US) What is the structure of a simple statement assessment? - ANSWERSAge and sex, PMHx if relevant, and diagnosis Name four items besides diagnosis that are included in a comprehensive summary assessment - ANSWERSDDx if relevant, Summary of PMHx, summary of PE, Chief Complaint, Prognosis True/False: A diagnosis or a differential diagnosis will always be listed in the assessment. - ANSWERSTRUE Name three things you can document in the General/Constitutional section for a normal peds exam? - ANSWERSAlert, interactive, smiling, cries with tears Why is it important that the patient is producing tears if crying? - ANSWERSThat can denote hydration What does A&OX4 mean? - ANSWERSAlert and oriented times 4 (person, place, time, or situation) Name two signs of respiratory distress in a peds pt. - ANSWERSWheezing, stridor, nasal flares, retractions Normal PE findings for Cardiovascular system - ANSWERSRRR, heart sounds normal Name normal PE findings for the pulmonary system - ANSWERSNo respiratory distress, CTAB (clear to auscultation bilaterally) Name normal PE findings for the abdominal system - ANSWERSSoft, non tender Name normal PE findings for the neurological system - ANSWERSA&OX4, normal speech, Non-focal neuro exam Name abnormal PE findings for the skin system - ANSWERSpallor, cyanosis, jaundice, diaphoresis, abrasion, laceration Name abnormal PE findings for the psychiatric system - ANSWERStearful, anxious, depressed, paranoid, tangential speech Name abnormal PE findings for the pulmonary system - ANSWERSrales, wheezes, tachypnea, accessory muscle use, rhonchi, diminished breath sounds, mild/moderate/severe respiratory distress CVA tenderness - ANSWERStenderness to percussion over a specific point in the flank where the kidneys lie (back) Paraspinal tenderness - ANSWERSmuscular tenderness around the spine (back) Pitting Pedal edema - ANSWERSSwelling of lower extremities, measured on a scale of trace to 4+ (musculoskeletal/ extremities) Melena - ANSWERSblack stool on glove Urticaria - ANSWERSHives/wheals (skin) Somnolent - ANSWERSunusually sleepiness (neurological) 5/5 strength in bilateral upper extremities - ANSWERSnormal motor strength in the upper extremities (neurological) 2+ patellar reflexes - ANSWERSknee reflexes intact and normal (neurological) EOM palsy - ANSWERSshifting of the pupils back and forth horizontally - a sign of benign positional vertigo (neurological) Name 10 body systems - ANSWERSConstitutional, HEENT, cardiovascular, respiratory, pulmonary, neurological, gastrointestinal, genitourinary, musculoskeletal, skin, endocrine, hematologic/lymph, immunologic, psychiatric. Name three types of HPI structures - ANSWERSSingle-complaint, multiple-complaint, and chronological Name all 8 elements in a complete HPI - ANSWERSOnset, timing, location, modifying factors, quality, severity, associated Sx, context What is the Peak Expiratory Flow (PEF) measured in? - ANSWERSLiters/minute Name inhaled pharmacological management for Asthma - ANSWERSpulmicort (steroid), advair, xopenex What type of medication can treat CAD? - ANSWERSASA, NTG How is CAD diagnosed? - ANSWERSCardiac Catheterization Name the five risk factors for CAD - ANSWERSHTN, HLD, DM, smoking, FHx55y/o What PE findings most closely associate with asthma? - ANSWERSWheezing, shortness of breath Name four risk factors of HLD - ANSWERSObesity, FHx, DM, EtOH abuse What symptoms would a person with HLD experience? - ANSWERSasymptomatic What is the name of the drug group you should immediately associate with HLD? - ANSWERSStatin Why is High Density Lipoprotein called "good cholesterol?" - ANSWERSBecause it can remove plaque and recycle it back to the liver What are insulin medications for DM? - ANSWERSHumalog (short acting) and Lantus (long acting) With a sliding scale insulin treatment, the pt adjusts the dosage of insulin base on - ANSWERSCurren glucose levels What does HCTZ sand for and what type of drug is it? - ANSWERSHydrochlorothiazide, diuretic Can a patient be diagnosed with HTN without showing any symptoms? - ANSWERSYes What can be caused by both HTN and DM? - ANSWERSRenal failure, CHF, CAD What is a comorbidity? - ANSWERSThe simultaneous onset of two chronic, complex diseases Two was a comorbidity increases complexity is - ANSWERSadverse drug interactions, increased likelihood of organ failure if both diseases affect one organ system