TAUC Pre-Scribe U Exam Questions
and Answers 100% Pass
What should be consistently documented in the Procedures section for billing
purposes? - ✔✔Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? - ✔✔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? - ✔✔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)
Katelyn Whitman, All Rights Reserved © 2025 1
,When documenting discussions with external professionals what must you include? -
✔✔Document any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? - ✔✔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? - ✔✔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? - ✔✔Choose the numbered
choices from the bottom section (top 4)
-Acute
Katelyn Whitman, All Rights Reserved © 2025 2
,-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? - ✔✔Clinical not possible and you must
include an associated fracture dx
Should you document any refused procedures in the procedure note? - ✔✔yes
Can diagnosis modifiers be modified at a later time? - ✔✔Yes in the diagnosis screen by
clicking on "dx mod" button
Are charts coded by providers? - ✔✔No
What do you do if the common diagnosis list does not contain the diagnosis you need? -
✔✔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? -
✔✔Laterality, visit number, further specification of anatomy
Katelyn Whitman, All Rights Reserved © 2025 3
, What can you do if you are unable to locate the exact diagnosis? - ✔✔Rename the
diagnosis by typing in the rename bar
A plan is not created for every diagnosis... T/F - ✔✔FALSE
What does a plan contain? - ✔✔Advice
Referral options
Discharge instructions
RX
Every plan should include how many items/topics that are chosen under the advice? -
✔✔3
If a parent received an XR, CT, US during their visit, what should you do? - ✔✔Select
lab and XR sent with patient
-you then right click the bullet point and choose "nurse-todo list"
What does every referral include? - ✔✔A STL region associated with it.
How many referrals should you select in the same region as the TAUC location? - ✔✔2-
4
What do you do if no options are listed? - ✔✔Click on referral options and choose the
specialty
Katelyn Whitman, All Rights Reserved © 2025 4
and Answers 100% Pass
What should be consistently documented in the Procedures section for billing
purposes? - ✔✔Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? - ✔✔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? - ✔✔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)
Katelyn Whitman, All Rights Reserved © 2025 1
,When documenting discussions with external professionals what must you include? -
✔✔Document any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? - ✔✔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? - ✔✔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? - ✔✔Choose the numbered
choices from the bottom section (top 4)
-Acute
Katelyn Whitman, All Rights Reserved © 2025 2
,-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? - ✔✔Clinical not possible and you must
include an associated fracture dx
Should you document any refused procedures in the procedure note? - ✔✔yes
Can diagnosis modifiers be modified at a later time? - ✔✔Yes in the diagnosis screen by
clicking on "dx mod" button
Are charts coded by providers? - ✔✔No
What do you do if the common diagnosis list does not contain the diagnosis you need? -
✔✔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? -
✔✔Laterality, visit number, further specification of anatomy
Katelyn Whitman, All Rights Reserved © 2025 3
, What can you do if you are unable to locate the exact diagnosis? - ✔✔Rename the
diagnosis by typing in the rename bar
A plan is not created for every diagnosis... T/F - ✔✔FALSE
What does a plan contain? - ✔✔Advice
Referral options
Discharge instructions
RX
Every plan should include how many items/topics that are chosen under the advice? -
✔✔3
If a parent received an XR, CT, US during their visit, what should you do? - ✔✔Select
lab and XR sent with patient
-you then right click the bullet point and choose "nurse-todo list"
What does every referral include? - ✔✔A STL region associated with it.
How many referrals should you select in the same region as the TAUC location? - ✔✔2-
4
What do you do if no options are listed? - ✔✔Click on referral options and choose the
specialty
Katelyn Whitman, All Rights Reserved © 2025 4
