SCRIBEAMERICA OP EVALUATION EXAM 2025 QUESTIONS
WITH ANSWERS GUARANTEE A+
✔✔HOW IS THE PLAN WRITTEN - ✔✔• Each item should appear on a separate line.
• Bulleted or numbered list
• At least one bullet/number to address each diagnosis
• Last bullet/number should always include the timeline for follow-up in the office.
✔✔HOW IS THE PLAN WRITTEN - ✔✔Example Format for a Plan:
PLAN:
- Treatment plan for diagnosis 1
- Treatment plan for diagnosis 2
- Follow-up with specialist in *** days for ***
- Follow-up here in *** weeks for re-evaluation
✔✔THE PLAN IS WRITTEN IN THE ROOM - ✔✔Providers often dictate their
assessments and plans verbatim to the patient while in the room.
Hints:
-Do not "tune out" after you have written your HPI.
-Have the provider read, summarize, and make adjustments to your plan outside of the
room.
-If a part of the plan is unclear, ask your provider to clarify upon leaving the room.
✔✔EXAMPLE PLAN - FAMILY PRACTICE - ✔✔PLAN - Diabetes Mellitus and
Hypertension:
1. Strictly follow metformin regimen as prescribed
2. Continue adherence to diabetic diet
3. If HbA1c has not improved next visit, will start insulin
4. Continue taking HCTZ as prescribed
5. Continue BP log
6. Will refill both metformin and HCTZ today
7. Follow up in 3 months for repeat A1c and BP check
✔✔EXAMPLE PLAN - ORTHOPEDICS - ✔✔PLAN - Right Wrist Fracture:
1. Waterproof short-arm cast applied today
2. Restricted activities for the next 3 weeks
3. 800mg Motrin prescribed today - take prn
4. Return in 4 weeks for cast off and repeat XR
,✔✔EXAMPLE PLAN - PEDIATRICS - ✔✔PLAN - Upper Respiratory Infection:
1. Alternate Tylenol/Motrin for pain
2. Push fluids
3. Off school for two days
4. Return in one week, sooner if worse
✔✔assessment formats - ✔✔Note! Not all assessment and plan sections will be in
these formats.
Sections will vary by EMR and Clinics so make sure to ask which structure your site
uses when you arrive!
✔✔MACRA - ✔✔Medicare Access and CHIP Reauthorization Act
✔✔CMS - ✔✔Centers for Medicare & Medicaid Services
✔✔MIPS - ✔✔Merit-based Incentive Payment System
✔✔CPOE - ✔✔Computerized physician order entry
✔✔EHR - ✔✔Electronic health record
✔✔EMR - ✔✔Electronic medical record
✔✔HIPAA - ✔✔Health Insurance Portability and Accountability Act
✔✔PHI - ✔✔Protected health information
✔✔MACRA - ✔✔In this lesson, we will address the following question:
What is MACRA?
MACRA is a payment model for physicians that began on
January 1st, 2017. It is run by CMS, the Centers for Medicare and Medicaid Services.
As the largest payer for healthcare in the United States, CMS sets the stage for how all
doctors are paid for their services.
✔✔MACRA - ✔✔How are doctors paid?
Fee for service: Providers are paid a set fee for each
service they provide. In essence, the MORE a doctor does, the more he gets paid. ------
> (CMS) ------> Value based care: Providers are paid more for better
quality of care and improved outcomes.
,✔✔MACRA- MIPS - ✔✔How does MACRA incentivize providers to improve quality of
care?
MERIT-BASED INCENTIVE
PAYMENT SYSTEM
Doctors who prove high
quality and better outcomes
can receive large bonus
payments from CMS. Those
with poor quality are
penalized financially.
✔✔MACRA- MIPS - ✔✔The payment adjustments under MIPS are
significant and increase over time.
Physicians receive their payment adjustments by
reporting on a number of QUALITY MEASURES that
must be recorded in a specific location in the EMR.
Your manager will tell you which quality measures
are being tracked at your facility.
✔✔quality measure examples - ✔✔Measure 1, 2, 3...: smoking cessation, avoiding ABx
overuse, exercise counseling
✔✔scribe impact - ✔✔Due to your close proximity to the providers, you can help them
meet their MACRA/MIPS goals by ensuring the correct information is documented for
each quality measure. QUALITY
✔✔SCRIBE IMPACT - ✔✔Your manager will provide you with a tracking sheet that has
your
clinic's quality measures listed. Use this to keep track of any patients that meet criteria
for the quality measures.
Make sure the quality measures are
documented in the correct area of the patient's chart. Ask your manager or provider for
clarification
if needed.
EXAMPLE:
● One of the clinic's quality measures is
exercise counseling for obese patients
● Sally Scribe notes that patient Bob has
a BMI of 31.5
● Sally reminds her provider to counsel
, the patient
● She then documents the counseling in
the appropriate section of the patient's
chart
✔✔Tracking sheet example - ✔✔Boxes including (image): Afib, Tob, FHx, HTN, BMI,
DM
Your manager will provide you with a tracking sheet that has your clinic's quality
measures listed. Use this to keep track of any patients that meet criteria for the quality
measures.
Make sure the quality measures are documented in the
correct area of the patient's chart. Ask your manager or
provider for clarification if needed.
✔✔HIPAA - ✔✔HIPAA stands for the Health Insurance Portability and Accountability
Act, which is a body of laws designed to protect the private
health information of patients across the country.
✔✔PHI - ✔✔PHI stands for protected health information and it refers to ANY
type of information that can be directly or indirectly tied to a particular patient or visit:
Included but not limited to:
• First or last name
• Date of birth
• Medical record number
• Even the fact that the patient was seen in your clinic
✔✔5.7:Types of PHI - ✔✔●Patient name
● Geographic subdivisions
● Telephone numbers
● Email addresses
● Fax Numbers
● Health Plan beneficiary
numbers
●Social Security Numbers
● Certificate/license numbers
● Healthcare Record numbers
● Account Numbers
● Dates (except years)
● Any other Unique number, code, or
characteristic that can be linked to an
individual
WITH ANSWERS GUARANTEE A+
✔✔HOW IS THE PLAN WRITTEN - ✔✔• Each item should appear on a separate line.
• Bulleted or numbered list
• At least one bullet/number to address each diagnosis
• Last bullet/number should always include the timeline for follow-up in the office.
✔✔HOW IS THE PLAN WRITTEN - ✔✔Example Format for a Plan:
PLAN:
- Treatment plan for diagnosis 1
- Treatment plan for diagnosis 2
- Follow-up with specialist in *** days for ***
- Follow-up here in *** weeks for re-evaluation
✔✔THE PLAN IS WRITTEN IN THE ROOM - ✔✔Providers often dictate their
assessments and plans verbatim to the patient while in the room.
Hints:
-Do not "tune out" after you have written your HPI.
-Have the provider read, summarize, and make adjustments to your plan outside of the
room.
-If a part of the plan is unclear, ask your provider to clarify upon leaving the room.
✔✔EXAMPLE PLAN - FAMILY PRACTICE - ✔✔PLAN - Diabetes Mellitus and
Hypertension:
1. Strictly follow metformin regimen as prescribed
2. Continue adherence to diabetic diet
3. If HbA1c has not improved next visit, will start insulin
4. Continue taking HCTZ as prescribed
5. Continue BP log
6. Will refill both metformin and HCTZ today
7. Follow up in 3 months for repeat A1c and BP check
✔✔EXAMPLE PLAN - ORTHOPEDICS - ✔✔PLAN - Right Wrist Fracture:
1. Waterproof short-arm cast applied today
2. Restricted activities for the next 3 weeks
3. 800mg Motrin prescribed today - take prn
4. Return in 4 weeks for cast off and repeat XR
,✔✔EXAMPLE PLAN - PEDIATRICS - ✔✔PLAN - Upper Respiratory Infection:
1. Alternate Tylenol/Motrin for pain
2. Push fluids
3. Off school for two days
4. Return in one week, sooner if worse
✔✔assessment formats - ✔✔Note! Not all assessment and plan sections will be in
these formats.
Sections will vary by EMR and Clinics so make sure to ask which structure your site
uses when you arrive!
✔✔MACRA - ✔✔Medicare Access and CHIP Reauthorization Act
✔✔CMS - ✔✔Centers for Medicare & Medicaid Services
✔✔MIPS - ✔✔Merit-based Incentive Payment System
✔✔CPOE - ✔✔Computerized physician order entry
✔✔EHR - ✔✔Electronic health record
✔✔EMR - ✔✔Electronic medical record
✔✔HIPAA - ✔✔Health Insurance Portability and Accountability Act
✔✔PHI - ✔✔Protected health information
✔✔MACRA - ✔✔In this lesson, we will address the following question:
What is MACRA?
MACRA is a payment model for physicians that began on
January 1st, 2017. It is run by CMS, the Centers for Medicare and Medicaid Services.
As the largest payer for healthcare in the United States, CMS sets the stage for how all
doctors are paid for their services.
✔✔MACRA - ✔✔How are doctors paid?
Fee for service: Providers are paid a set fee for each
service they provide. In essence, the MORE a doctor does, the more he gets paid. ------
> (CMS) ------> Value based care: Providers are paid more for better
quality of care and improved outcomes.
,✔✔MACRA- MIPS - ✔✔How does MACRA incentivize providers to improve quality of
care?
MERIT-BASED INCENTIVE
PAYMENT SYSTEM
Doctors who prove high
quality and better outcomes
can receive large bonus
payments from CMS. Those
with poor quality are
penalized financially.
✔✔MACRA- MIPS - ✔✔The payment adjustments under MIPS are
significant and increase over time.
Physicians receive their payment adjustments by
reporting on a number of QUALITY MEASURES that
must be recorded in a specific location in the EMR.
Your manager will tell you which quality measures
are being tracked at your facility.
✔✔quality measure examples - ✔✔Measure 1, 2, 3...: smoking cessation, avoiding ABx
overuse, exercise counseling
✔✔scribe impact - ✔✔Due to your close proximity to the providers, you can help them
meet their MACRA/MIPS goals by ensuring the correct information is documented for
each quality measure. QUALITY
✔✔SCRIBE IMPACT - ✔✔Your manager will provide you with a tracking sheet that has
your
clinic's quality measures listed. Use this to keep track of any patients that meet criteria
for the quality measures.
Make sure the quality measures are
documented in the correct area of the patient's chart. Ask your manager or provider for
clarification
if needed.
EXAMPLE:
● One of the clinic's quality measures is
exercise counseling for obese patients
● Sally Scribe notes that patient Bob has
a BMI of 31.5
● Sally reminds her provider to counsel
, the patient
● She then documents the counseling in
the appropriate section of the patient's
chart
✔✔Tracking sheet example - ✔✔Boxes including (image): Afib, Tob, FHx, HTN, BMI,
DM
Your manager will provide you with a tracking sheet that has your clinic's quality
measures listed. Use this to keep track of any patients that meet criteria for the quality
measures.
Make sure the quality measures are documented in the
correct area of the patient's chart. Ask your manager or
provider for clarification if needed.
✔✔HIPAA - ✔✔HIPAA stands for the Health Insurance Portability and Accountability
Act, which is a body of laws designed to protect the private
health information of patients across the country.
✔✔PHI - ✔✔PHI stands for protected health information and it refers to ANY
type of information that can be directly or indirectly tied to a particular patient or visit:
Included but not limited to:
• First or last name
• Date of birth
• Medical record number
• Even the fact that the patient was seen in your clinic
✔✔5.7:Types of PHI - ✔✔●Patient name
● Geographic subdivisions
● Telephone numbers
● Email addresses
● Fax Numbers
● Health Plan beneficiary
numbers
●Social Security Numbers
● Certificate/license numbers
● Healthcare Record numbers
● Account Numbers
● Dates (except years)
● Any other Unique number, code, or
characteristic that can be linked to an
individual
