SCRIBE TRAINING COURSE EXAM
QUESTIONS AND ANSWERS
Scribes help physicians ensure and improve (5) - Answer-Pt care and satisfaction
Depth and accuracy of documentation
Insurance compensation
Legal protection
Pt throughput (pt seen per shift)
What are scribe connect core values? (6) - Answer-Service excellence
Collaboration
Reliability
Integrity
Balance
Efficiency
What is a scribe? - Answer-An unlicensed individual hired to enter info into the EHR or
chart at the direction of a physician or licensed independent practitioner
What is SOAP - Answer-Subjective
Objective
Assessment
Plan
Components of Subjective. What it is. - Answer-CC
HPI
PFSH
ROS
Based on what the pt tells you, not observation-based
Components of Objective. What it is. - Answer-PE
Based on factual observations and findings identified by the physician on the PE, and
diagnostic tools
Components of Assessment and Plan. - Answer-MDM
CC - Answer-Chief complaint
HPI - Answer-History of present illness
PFSH - Answer-Past, family, and social history
ROS - Answer-Review of systems
, PE - Answer-Physical examination
MDM - Answer-Medical decision making
Definition of diagnose - Answer-To recognize as a disease by signs and symptoms, to
diagnose a disease or condition in a pt
Definition of differential diagnosis - Answer-A process of identifying all possible
diagnoses that could be connected to the signs and symptoms presented by a pt, then
ruling out diagnoses until a final determination can be made.
Definition of definitive diagnosis - Answer-A diagnosis reached by an extensive work up
upon which a management plan may be based, including therapy, tx, follow up. This
may include a list of possible or multiple co-existing conditions, ranked in probability or
severity.
What are diagnostic tools - Answer-Clinical tools that may be used to rule in or out
various diseases in order to arrive at a final diagnosis. (Labs, x-Rays, physical exams,
symptoms pt denies or admits)
What is HIPAA - Answer-Health insurance portability and accountability act of 1996. Set
the first national standards for the protection of pt health information.
TJC - Answer-The joint commission is an independent non-profit organization that is
responsible for evaluating, accrediting, and certifying health care organizations and
programs in the U.S. With a goal to improve public health care. It evaluates and
provides incentives.
Privacy rule - Answer-Protects all individually identifiable health information (what pt info
is protected and whom, as well as how info may be used and disclosed) (PHI)
PHI - Answer-Protected health information
What are individually identifiable health information - Answer-Any info that can be used
to identify or relate to the pt. such as name, DOB, contact info, SS.
Security rule - Answer-Federal protection for personal health information that is created,
received, used, or maintained by a covered entity. Sets standards and regulations
regarding security measures to ensure confidentiality of EHR (electronic PHI)
What are the 3 security rule safeguards - Answer-Administrative
Physical
Technical
QUESTIONS AND ANSWERS
Scribes help physicians ensure and improve (5) - Answer-Pt care and satisfaction
Depth and accuracy of documentation
Insurance compensation
Legal protection
Pt throughput (pt seen per shift)
What are scribe connect core values? (6) - Answer-Service excellence
Collaboration
Reliability
Integrity
Balance
Efficiency
What is a scribe? - Answer-An unlicensed individual hired to enter info into the EHR or
chart at the direction of a physician or licensed independent practitioner
What is SOAP - Answer-Subjective
Objective
Assessment
Plan
Components of Subjective. What it is. - Answer-CC
HPI
PFSH
ROS
Based on what the pt tells you, not observation-based
Components of Objective. What it is. - Answer-PE
Based on factual observations and findings identified by the physician on the PE, and
diagnostic tools
Components of Assessment and Plan. - Answer-MDM
CC - Answer-Chief complaint
HPI - Answer-History of present illness
PFSH - Answer-Past, family, and social history
ROS - Answer-Review of systems
, PE - Answer-Physical examination
MDM - Answer-Medical decision making
Definition of diagnose - Answer-To recognize as a disease by signs and symptoms, to
diagnose a disease or condition in a pt
Definition of differential diagnosis - Answer-A process of identifying all possible
diagnoses that could be connected to the signs and symptoms presented by a pt, then
ruling out diagnoses until a final determination can be made.
Definition of definitive diagnosis - Answer-A diagnosis reached by an extensive work up
upon which a management plan may be based, including therapy, tx, follow up. This
may include a list of possible or multiple co-existing conditions, ranked in probability or
severity.
What are diagnostic tools - Answer-Clinical tools that may be used to rule in or out
various diseases in order to arrive at a final diagnosis. (Labs, x-Rays, physical exams,
symptoms pt denies or admits)
What is HIPAA - Answer-Health insurance portability and accountability act of 1996. Set
the first national standards for the protection of pt health information.
TJC - Answer-The joint commission is an independent non-profit organization that is
responsible for evaluating, accrediting, and certifying health care organizations and
programs in the U.S. With a goal to improve public health care. It evaluates and
provides incentives.
Privacy rule - Answer-Protects all individually identifiable health information (what pt info
is protected and whom, as well as how info may be used and disclosed) (PHI)
PHI - Answer-Protected health information
What are individually identifiable health information - Answer-Any info that can be used
to identify or relate to the pt. such as name, DOB, contact info, SS.
Security rule - Answer-Federal protection for personal health information that is created,
received, used, or maintained by a covered entity. Sets standards and regulations
regarding security measures to ensure confidentiality of EHR (electronic PHI)
What are the 3 security rule safeguards - Answer-Administrative
Physical
Technical
