Scribe Final Exam Test with Answers | Graded A
What medical term describes the surgical removal of the
gallbladder? Word - ANSWER -Cholecystectomy
What medical term would describe a patient with a history of
infection or inflammation of the liver? - ANSWER -Hepatitis
What does "PHI" stand for? Expand the abbreviation -
ANSWER -Protected Health Information
For correct billing and reimbursement to go through, a
counseling note requires documentation of the following: -
T/F Sharing information about a case with family is allowed, as ANSWER -Total time with the patient
long as you are scribing with the physician assigned to the case Percentage of the time spent counseling
- ANSWER -F
You are writing an HPI for a very complex patient who has had
A patient underwent brain surgery to treat bleeding in the brain multiple recent hospital admissions for lung cancer. Which HPI
from a stroke. What PSHx would you record into the chart? - structure would be the best to use in this scenario? -
ANSWER -***NOT Hemorrhagic CVA ANSWER -Chronologic Structure
Craniotomy for hemorrhagic CVA
OR Craniotomy?? Which of the following would be valid complications for CAD? -
ANSWER -MI
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 Read the following HPI and verify whether this HPI meets Level
has never been seen by the NP before. Is this patient 4 billing criteria for a NEW patient:
considered a new patient or an established patient? -
ANSWER -Established 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
A patient is diagnosed with back strain caused by heavy lifting. yesterday without relief. There has been no nausea, vomiting or
As part of the treatment, the physician discusses 4-5 different diarrhea. - ANSWER -Yes, the HPI meets Level 4 billing
back stretching exercises that the patient can perform every criteria
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 What are the possible consequences of a HIPAA violation? -
patient? - ANSWER -Yes ANSWER -Lawsuit against you and the hospital
Monetary fines to you and the hospital
Scribe program cancellation
What medical term would best describe "the likely course or Termination
outcome of a disease"? - ANSWER -Prognosis Prison time
Violator is blacklisted from medical programs like Medical, PA,
or NP school
Which section of the chart should you document when you hear
the following cue "what medical problems do you have"? -
ANSWER -PHx What does HIPAA stand for? Expand the abbreviation. -
ANSWER -Health Insurance Portability & Accountability
Act
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 What chronic condition would require diagnosis through fasting
symptoms. Which HPI structure would be the best to use in this blood glucose level or HbA1c? - ANSWER -Diabetes
scenario? - ANSWER -Multiple Complaint structure Mellitus
Which of the following is NOT a purpose of HITECH? - A patient states she has had a productive cough for 4 days, and
ANSWER -To require government accountability on health yesterday she developed a fever. Would her fever be
insurance plans available in the market place considered an associated symptom for her productive cough?
To require equal access, opportunity, and affordability for health Why or why not? - ANSWER -Yes, because the fever
insurance plans by screening patient health information started soon after the cough
To require patient accountability in paying for their health care
visit
1/6
, Scribe Final Exam Test with Answers | Graded A
Which of the following would be documented in the Objective What PMHx would you record into the chart? (abbrev) -
section of the SOAP note? - ANSWER - ANSWER -BPH
Interpretations/results
orders
treatments A patient is s/p angioplasty with stent and quadruple cardiac
PE bypass. What chronic condition should be included in their
diagnosis today? Expand the abbreviation. (Remember do not
include spaces before or after your answer.) - ANSWER -
HIPAA is a set of laws designed to - ANSWER -maintain Coronary Artery Disease
patient privacy and confidentiality
A patient states that he has been having abdominal pain for the
What condition correctly describes "blood clot in the lungs"? last three days, and it varies between mild and severe. Which of
(Use abbreviation) - ANSWER -PE the following would best describe the Timing? - ANSWER -
Waxing and waning
Matching the following description with the corresponding term.
- ANSWER -MACRA = government healthcare initiative Which of the following would be included in a Problem List? -
that focuses on quality of care to improve patient outcomes ANSWER -Pyelonephritis, resolved
MIPS = system of payment in which government funding is Nephrolithiasis, stable
released if specific quality measures are tracked
Quality Measures = site specific health criteria that are tracked
What condition correctly describes "heart attack"? (abbrev) -
ANSWER -MI
Match the following scenario to the corresponding risk. -
ANSWER -Moderate risk = asthmatic patient with acute
acerbation that is resolved in office with nebulizer treatment An elderly male patient has a history of an enlarged prostate
High risk = patient with acute exerbation of ESRD requiring and has undergone surgery to treat his condition. What PSHx
emergency dialysis would you record into the chart? - ANSWER -TURP
Low risk = patient with stable HTN and no other comordibities
What medical term is used to describe the symptom of a
What chronic condition would require diagnosis through a lipid patient's heart beating rapidly, irregularly, or forcibly? -
panel? (abbrev) - ANSWER -HLD ANSWER -Arrhythmia
Which of the following are considered non-reimbursable chief Identify what details are included in the following Assessment.
complaints? - ANSWER -Medication refill (Select all that apply.)
lab results
follow up "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in
check uo acute exacerbation today. He reports decreased urinary output
that has progressively worsened since onset 5 days ago.
Creatinine and BUN elevated and worsening compared to last
What does "CP" stand for? - ANSWER -Chest Pain visit 3 weeks ago. Patient recommended emergency dialysis
today and warned that he may be at risk for death and other
complications if he does not seek further urgent medical
T/F. A family friend was recently evaluated for IDDM and lost attention. Patient understands and agrees to be transferred to
his paperwork and does not know what medications he should the ED." - ANSWER -age and sex
be taking at home. He asks you to look up his medical record PHx, if relevant
when you go to your shift today, giving you verbal permission to HPI
access his information. In this scenario, it is justifiable for you to Diagnosis
use your EMR login to look up the important patient information. Prognosis/plan
- ANSWER -F results
What condition correctly describes "dangerous infection of the T/F. All symptoms documented in the ROS are also documented
appendix"? - ANSWER -appendicitis in the HPI. - ANSWER -T
An elderly male patient has a history of an enlarged prostate. What is the medical term for "open heart surgery"? Hint: expand
2/6
What medical term describes the surgical removal of the
gallbladder? Word - ANSWER -Cholecystectomy
What medical term would describe a patient with a history of
infection or inflammation of the liver? - ANSWER -Hepatitis
What does "PHI" stand for? Expand the abbreviation -
ANSWER -Protected Health Information
For correct billing and reimbursement to go through, a
counseling note requires documentation of the following: -
T/F Sharing information about a case with family is allowed, as ANSWER -Total time with the patient
long as you are scribing with the physician assigned to the case Percentage of the time spent counseling
- ANSWER -F
You are writing an HPI for a very complex patient who has had
A patient underwent brain surgery to treat bleeding in the brain multiple recent hospital admissions for lung cancer. Which HPI
from a stroke. What PSHx would you record into the chart? - structure would be the best to use in this scenario? -
ANSWER -***NOT Hemorrhagic CVA ANSWER -Chronologic Structure
Craniotomy for hemorrhagic CVA
OR Craniotomy?? Which of the following would be valid complications for CAD? -
ANSWER -MI
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 Read the following HPI and verify whether this HPI meets Level
has never been seen by the NP before. Is this patient 4 billing criteria for a NEW patient:
considered a new patient or an established patient? -
ANSWER -Established 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
A patient is diagnosed with back strain caused by heavy lifting. yesterday without relief. There has been no nausea, vomiting or
As part of the treatment, the physician discusses 4-5 different diarrhea. - ANSWER -Yes, the HPI meets Level 4 billing
back stretching exercises that the patient can perform every criteria
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 What are the possible consequences of a HIPAA violation? -
patient? - ANSWER -Yes ANSWER -Lawsuit against you and the hospital
Monetary fines to you and the hospital
Scribe program cancellation
What medical term would best describe "the likely course or Termination
outcome of a disease"? - ANSWER -Prognosis Prison time
Violator is blacklisted from medical programs like Medical, PA,
or NP school
Which section of the chart should you document when you hear
the following cue "what medical problems do you have"? -
ANSWER -PHx What does HIPAA stand for? Expand the abbreviation. -
ANSWER -Health Insurance Portability & Accountability
Act
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 What chronic condition would require diagnosis through fasting
symptoms. Which HPI structure would be the best to use in this blood glucose level or HbA1c? - ANSWER -Diabetes
scenario? - ANSWER -Multiple Complaint structure Mellitus
Which of the following is NOT a purpose of HITECH? - A patient states she has had a productive cough for 4 days, and
ANSWER -To require government accountability on health yesterday she developed a fever. Would her fever be
insurance plans available in the market place considered an associated symptom for her productive cough?
To require equal access, opportunity, and affordability for health Why or why not? - ANSWER -Yes, because the fever
insurance plans by screening patient health information started soon after the cough
To require patient accountability in paying for their health care
visit
1/6
, Scribe Final Exam Test with Answers | Graded A
Which of the following would be documented in the Objective What PMHx would you record into the chart? (abbrev) -
section of the SOAP note? - ANSWER - ANSWER -BPH
Interpretations/results
orders
treatments A patient is s/p angioplasty with stent and quadruple cardiac
PE bypass. What chronic condition should be included in their
diagnosis today? Expand the abbreviation. (Remember do not
include spaces before or after your answer.) - ANSWER -
HIPAA is a set of laws designed to - ANSWER -maintain Coronary Artery Disease
patient privacy and confidentiality
A patient states that he has been having abdominal pain for the
What condition correctly describes "blood clot in the lungs"? last three days, and it varies between mild and severe. Which of
(Use abbreviation) - ANSWER -PE the following would best describe the Timing? - ANSWER -
Waxing and waning
Matching the following description with the corresponding term.
- ANSWER -MACRA = government healthcare initiative Which of the following would be included in a Problem List? -
that focuses on quality of care to improve patient outcomes ANSWER -Pyelonephritis, resolved
MIPS = system of payment in which government funding is Nephrolithiasis, stable
released if specific quality measures are tracked
Quality Measures = site specific health criteria that are tracked
What condition correctly describes "heart attack"? (abbrev) -
ANSWER -MI
Match the following scenario to the corresponding risk. -
ANSWER -Moderate risk = asthmatic patient with acute
acerbation that is resolved in office with nebulizer treatment An elderly male patient has a history of an enlarged prostate
High risk = patient with acute exerbation of ESRD requiring and has undergone surgery to treat his condition. What PSHx
emergency dialysis would you record into the chart? - ANSWER -TURP
Low risk = patient with stable HTN and no other comordibities
What medical term is used to describe the symptom of a
What chronic condition would require diagnosis through a lipid patient's heart beating rapidly, irregularly, or forcibly? -
panel? (abbrev) - ANSWER -HLD ANSWER -Arrhythmia
Which of the following are considered non-reimbursable chief Identify what details are included in the following Assessment.
complaints? - ANSWER -Medication refill (Select all that apply.)
lab results
follow up "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in
check uo acute exacerbation today. He reports decreased urinary output
that has progressively worsened since onset 5 days ago.
Creatinine and BUN elevated and worsening compared to last
What does "CP" stand for? - ANSWER -Chest Pain visit 3 weeks ago. Patient recommended emergency dialysis
today and warned that he may be at risk for death and other
complications if he does not seek further urgent medical
T/F. A family friend was recently evaluated for IDDM and lost attention. Patient understands and agrees to be transferred to
his paperwork and does not know what medications he should the ED." - ANSWER -age and sex
be taking at home. He asks you to look up his medical record PHx, if relevant
when you go to your shift today, giving you verbal permission to HPI
access his information. In this scenario, it is justifiable for you to Diagnosis
use your EMR login to look up the important patient information. Prognosis/plan
- ANSWER -F results
What condition correctly describes "dangerous infection of the T/F. All symptoms documented in the ROS are also documented
appendix"? - ANSWER -appendicitis in the HPI. - ANSWER -T
An elderly male patient has a history of an enlarged prostate. What is the medical term for "open heart surgery"? Hint: expand
2/6
