ScribeAmerica - FINAL EXAM - GENERAL OP Score 80 -
90% to pass GUARANTEED SUCCESS 2025/2026 NEW
EDITION
Cholecystectomy
What medical term describes the surgical removal of the gallbladder?
Protected Health Informa on
What does PHI stand for? Expand the abbrevia on.
False
T/F Sharing informa on about a case with family is allowed, as long as you are scribing with the
physician assigned to the case.
Craniotomy
A pa ent underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record in the chart?
Established
A pa ent's PCP is on vaca on. The pa ent is scheduled to see the NP who is covering for the
PCP during this me. The pa ent has never been seen by the NP before is this pa ent
considered a new pa ent or an establish pa ent?
Yes
A Pa ent is diagnosed with back strain caused by heavy li+ing. As part of the treatment, the
physician discusses 4-5 different back stretching exercises that the pa ent can perform every
morning and before doing any heavy li+ing. The discussion only takes 10 minutes of a 15 minute
Established pa ent visit. Would your physician be able to bill counseling me on this pa ent?
Prognosis
What medical term would best describe " the likely course or outcome of a disease?"
PHx
What sec on of the chart should you document when you hear the following cue "what medical
problems do you have?"
, Mul ple Complaints Structure
You are wri ng an HPI for a pa ent who presented for hyperlipidemia management. In the
middle of the visit, your pa ent also reports having recently experienced urinary symptoms.
Which HPI structure would be the best to use in this scenario?
require pa ent accountability in paying for their health care visit (select)
require pa ent privacy and confiden ality
require government accountability on health insurance plans available in the market place
(select)
require equal access, opportunity, and affordability for health insurance plans by screening
pa ent health informa on (select)
require encryp on when using technology to transmit pa ent related informa on
Which of the following is NOT A PURPOSE OF HITECH select all that apply
Hepa s
What medical term would describe a pa ent with a history of infec on or inflamma on of the
liver?
Total me with the pa ent
Percentage of me spent counseling
For correct billing and reimbursement to go through, a counseling note requires documenta on
of the following
Chronologic Structure
You are wri ng an HPI for a very complex pa ent who has had mul ple recent hospital
admissions for lung cancer. Which HPI structure would be the best to use in this scenario?
MI
Which of the following would be valid complica ons for CAD?
Yes, the HPI meets Level 4 billing criteria.
90% to pass GUARANTEED SUCCESS 2025/2026 NEW
EDITION
Cholecystectomy
What medical term describes the surgical removal of the gallbladder?
Protected Health Informa on
What does PHI stand for? Expand the abbrevia on.
False
T/F Sharing informa on about a case with family is allowed, as long as you are scribing with the
physician assigned to the case.
Craniotomy
A pa ent underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record in the chart?
Established
A pa ent's PCP is on vaca on. The pa ent is scheduled to see the NP who is covering for the
PCP during this me. The pa ent has never been seen by the NP before is this pa ent
considered a new pa ent or an establish pa ent?
Yes
A Pa ent is diagnosed with back strain caused by heavy li+ing. As part of the treatment, the
physician discusses 4-5 different back stretching exercises that the pa ent can perform every
morning and before doing any heavy li+ing. The discussion only takes 10 minutes of a 15 minute
Established pa ent visit. Would your physician be able to bill counseling me on this pa ent?
Prognosis
What medical term would best describe " the likely course or outcome of a disease?"
PHx
What sec on of the chart should you document when you hear the following cue "what medical
problems do you have?"
, Mul ple Complaints Structure
You are wri ng an HPI for a pa ent who presented for hyperlipidemia management. In the
middle of the visit, your pa ent also reports having recently experienced urinary symptoms.
Which HPI structure would be the best to use in this scenario?
require pa ent accountability in paying for their health care visit (select)
require pa ent privacy and confiden ality
require government accountability on health insurance plans available in the market place
(select)
require equal access, opportunity, and affordability for health insurance plans by screening
pa ent health informa on (select)
require encryp on when using technology to transmit pa ent related informa on
Which of the following is NOT A PURPOSE OF HITECH select all that apply
Hepa s
What medical term would describe a pa ent with a history of infec on or inflamma on of the
liver?
Total me with the pa ent
Percentage of me spent counseling
For correct billing and reimbursement to go through, a counseling note requires documenta on
of the following
Chronologic Structure
You are wri ng an HPI for a very complex pa ent who has had mul ple recent hospital
admissions for lung cancer. Which HPI structure would be the best to use in this scenario?
MI
Which of the following would be valid complica ons for CAD?
Yes, the HPI meets Level 4 billing criteria.
