Scribe America OP Final Exam Questions With Correct Answers

* What medical term describes the surgical removal of the gallbladder? - Answer cholecystectomy What does "PHI" stand for? Expand the abbreviation. - 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. - Answer False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - 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? - 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? - Answer Yes 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 Which of the following is NOT a purpose of HITECH? - 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? - Answer Hepatitis For correct billing and reimbursement to go through, a counseling note requires documentation of the following: - 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? - Answer Chronologic structure Which of the following would be valid complications for CAD? - 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. - Answer Yes, the HPI meets Level 4 billing criteria. 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. Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ". - 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. - 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 * Which of the following would be documented in the Objective section of the SOAP note? (select all that apply.) - Answer - Orders - Interpretations/results - Treatments (that may involve medication or procedures) - Physical exam HIPAA is a set of laws designed to _______. (Select the best option.) - Answer maintain patient privacy and confidentiality What condition correctly describes "blood clot in the lungs"? (Use the abbreviation form of the condition) - Answer PE * MACRA - Answer government healthcare initiative that focuses on quality of care to improve patient outcomes. * MIPS - Answer system of payment in which government funding is released if specific quality measures are tracked Quality Measures - Answer site specific health criteria that are tracked High Risk - Answer Moderate Risk - Answer Low Risk - Answer 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? - Answer - Follow-up - Check-up - Medication refill - Lab results CP - Answer chest pain 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 F