TAUC Pre-Scribe U Exam Practice Questions and Answers

TAUC Pre-Scribe U Exam Practice Questions and Answers What should be consistently documented in the Procedures section for billing purposes? - Answer️️ -Prescription medication discussions Review of outside diagnostic results Discussions with external professionals Independent historians needed What is included in the prescription medication discussions? - Answer️️ -Document ll discussions regarding any prescription medicine that the patient is already taking whenever it is relevant to the current condition - Ex. BP meds for pt who is hypertensive Document when a pt refuses a prescription medicine recommended What is included in review of outside diagnostic results? - Answer️️ -Whenever a patient shows you outside labs or radiology results and asks you questions about them... Document: outside lab results reviewed and showed (insert interpretation) When documenting discussions with external professionals what must you include? - Answer️️ -Document any conversations you have with external sources such as: -ER triage nurse -Urgent specialist -External provider involved w/ pts care ©SOPHIABENNETT 2024/2025 9:45 AM Page | 2 -Non-healthcare professionals involved in pts management What do you document when independent historians are needed? - Answer️️ -When a pt is unable to provide a complete or reliable hx document discussions with another historian When selecting a dx modifier what should you not do? - Answer️️ -Do not select any of the three choices in the top under "uses for coding" -uncomplicated -systemic symptoms -poses a threat to life or bodily functions What do you select instead when selecting a dx modifier? - Answer️️ -Choose the numbered choices from the bottom section (top 4) -Acute -Chronic -Incidental lesion/mass Bottoms 6 are additions to top 4 What should all fractures be referred to as? - Answer️️ -Clinical not possible and you must include an associated fracture dx Should you document any refused procedures in the procedure note? - Answer️️ -yes Can diagnosis modifiers be modified at a later time? - Answer️️ -Yes in the diagnosis screen by clicking on "dx mod" button Are charts coded by providers? - Answer️️ -No ©SOPHIABENNETT 2024/2025 9:45 AM Page | 3 What do you do if the common diagnosis list does not contain the diagnosis you need? - Answer️️ -You can use the ICD-10 search function -Type the diagnosis you are searching for, select from list, this will take you to the next screen -Select a second more accurate diagnosis on the second screen After you select the diagnosis, what must you specify in the next screen? - Answer️️ - Laterality, visit number, further specification of anatomy What can you do if you are unable to locate the exact diagnosis? - Answer️️ -Rename the diagnosis by typing in the rename bar A plan is not created for every diagnosis... T/F - Answer️️ -FALSE What does a plan contain? - Answer️️ -Advice Referral options Discharge instructions RX Every plan should include how many items/topics that are chosen under the advice? - Answer️️ -3 If a parent received an XR, CT, US during their visit, what should you do? - Answer️️ - Select lab and XR sent with patient -you then right click the bullet point and choose "nurse-todo list" What does every referral include? - Answer️️ -A STL region associated with it. How many referrals should you select in the same region as the TAUC location? - Answer️️ -2-4 ©SOPHIABENNETT 2024/2025 9:45 AM Page | 4 What do you do if no options are listed? - Answer️️ -Click on referral options and choose the specialty If you are unable to find discharge instruction in docutap's global database, what are you able to do as an absolute last resort? - Answer️️ -Search for online resources What must you do once you select discharge instruction? - Answer️️ -Right-click and select "nurse-todo list" What must everyone who is seen for work comp have? - Answer️️ --"See RTW": return to work form -"Call made to employer-Bob" -Must list their next follow up If the Basic met panel w/ CK (metlyte) is ordered, do you need to order a BMP (ISTAT)? - Answer️️ -No If a provider requests a CMP what do you order? - Answer️️ -ISTAT BMP & Liver panel What does the uric acid panel (chem-13) include? - Answer️️ -Everything included in the liver panel plus some tests included in the BMP What should you double check when ordering medications? - Answer️️ -Drug, dose, route, and right patients chart What should you double check when ordering tetanus shot? - Answer️️ -Associated insurance Which tetanus shot does medicare support vs all other insurances? - Answer️️ -Td = mediare ©SOPHIABENNETT 2024/2025 9:45 AM Page | 5 Tdap = all other insurances What do you order if the pt needs a CT without IV fluids? - Answer️️ -IV catheter only What do your order if the pt has been seen by the provider but still needs the initial assessment performed by the tech? - Answer️️ -Initial vital When do you order TB read only? - Answer️️ -When TB skin test was placed at another facility but read here How can EKG's be documented? - Answer️️ -Free-text or procedure note What does free text order of EKG require? - Answer️️ -Rate, rhythm, axis, intervals, ST-T findinds What must all EKG's have? - Answer️️ -Labeled with patient sticker and scanned by the front desk staff after the provider signs EKGS What is the one exception for injections tab? - Answer️️ -"Inject, home med" -Techs utilize this order for medications not kept in stock at TAUC What are common orders used under the "Misc/other tab"? - Answer️️ -Tetracaine eye drops Fluorescein eye strips Visual acuity Eye irrigation Steri-strip What helps eliminate the need for further coding in physicals? - Answer️️ -Using preloaded physical codes ©SOPHIABENNETT 2024/2025 9:45 AM Page | 6 What are the different types of physicals? - Answer️️ -Private, school/sports, nursing home/childcare, DOT What are the 5 trauma CT's? - Answer️️ -CT head w/o IV contrast CT facial/sinuses complete w/o IV contrast CT c-spine w/o IV contrast CT chest (thorax) w/ IV contrast CT abdomen/pelvis w/ IV contrast What are the 5 medical CT's? - Answer️️ -CT head w/o IV contrast CT neck w/ IV contrast CT angio w/ IV contrast CT abdomen/pelvis w/ and w/o IV contrast What must you get for females prior to a CT? - Answer️️ -Pregnancy test in females 14-59 What must you have before all IV contrast studies? - Answer️️ -ISTAT with creatinine level What must you do when sending a patient to another location for a CT?