Scribe America Outpatient Final Exam Questions With Verified Answers

What does "PHI" stand for? Expand the abbreviation - Answer protected health information What medical term describes the surgical removal of the gallbladder? - Answer cholecystectomy T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case - Answer False A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP before. Is the patient considered a new patient or an established patient? - Answer Established What is the medical abbreviation for the condition commonly described as "reflux" - Answer GERD What medical term would best describe "the likely course or outcome of a disease?" - Answer prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have?" - 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? - Answer multiple complaints structure 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? - Answer chronological structure Which of the following would be valid complications for CAD? (Select all that apply) - Answer MI 11. What are the possible consequences of a HIPAA violation? (Select all that apply) - 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. - Answer Health Insurance Portability and Accountability Act What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? Two words, expand the abbreviation. - 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? - Answer Yes, because the fever started soon after the cough 15. Which of the following would be documented in the Objective section of the SOAP note? (select all that apply) - Answer *Orders *Interpretations/Results *Physical Exam HIPAA is a set of laws designed to__________. (select the best option) - Answer maintain patient privacy and confidentiality What is the medical abbreviation for the condition described as "blood clot in the lungs"? (Use the abbreviation form of the condition) - Answer PE What chronic condition would require diagnosis through a lipid panel? Use the abbreviation form. - Answer HLD Which of the following are considered non-reimbursable chief complaints? (Select all that apply) - Answer *follow-up *check-up *medication refill *lab results 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? - 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? - Answer tonsillectomy What is the medical term for an elevated heart rate (over 100 beats per minute)? - Answer tachycardia 27. 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