1
ScribeAmerica OP Final Questions & Verified
Answers | 100% Pass Rate Guaranteed | Latest
Updated Version
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
, 2
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
, 3
* 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
ScribeAmerica OP Final Questions & Verified
Answers | 100% Pass Rate Guaranteed | Latest
Updated Version
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
, 2
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
, 3
* 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
