SCRIBE AMERICA OP FINAL EXAM 2024/2025 NEWEST /COMPLETE
ACTUAL EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS ) ALREADY GRADED A+.
* 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
ACTUAL EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS ) ALREADY GRADED A+.
* 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
