Scribe America Outpatient Final Practice Questions With Correct Answers

What will the scribe document for the outpatient visit? - Answer Important 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? - Answer Nurse or MA What are the meaningful use requirements the nurse or MA will obtain? - Answer Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status What does H&P abbreviate and who performs this evaluation? - Answer History and Physical, physician Is a differential diagnosis necessary for a health maintenance visit? - Answer No, only for a diagnostic visit What information will be included in the patient's plan? - Answer Specialist follow-up, instructions for lifestyle and preventative care, routine follow-up The CBC shows anemia - Answer Results The EKG shows NSR - Answer Results The pt came to the clinic for chest pain - Answer HPI/ROS The pt also stubbed his toe last week - Answer HPI/ROS The pt is in no acute distress - Answer Physical Exam The pt has suffered from HTN for many years - Answer PMHx Thee is tenderness of the RUQ - Answer PE The pt's mother has heart disease - Answer FHX The diagnosis is upper respiratory infection - Answer Assessment The pt will be prescribed penicillin today - Answer Plan What age would a family member's cardiac disease indicate an increased risk for similar heart disease in the pt? - Answer <55 y/o What are three common general FHx your physician may ask about? - Answer HTN, CA, DM Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - Answer Yes Why must smoking status be documented on every patient 13 years and older? - Answer Meaningful use requirements HIPPA Rule 1 - Answer If a patient is not assigned to your doctor, do not touch the chart HIPAA Rule 2 - Answer There is always someone watching HIPAA Rule 3 - Answer Never share your username or password HIPAA Rule 4 - Answer Your job does not belong on social media HIPAA Rule 5 - Answer Ask yourself "Do I need to access this for my job?" HIPAA Rule 6 - Answer Do not store any protected health information (PHI) on non-approved systems HIPAA Rule 7 - Answer do not access family, friend or own medical record HIPAA Rule 8 - Answer No cell phones or pictures What should you do before leaving your workstation for the cafeteria? - Answer Log out What is the purpose of HIPAA? - Answer It is a body of laws designed to protect the private health information of patients across the country. What does PHI stand for? - Answer Protected Health Information