ScribeAmerica OP Final Exam
Questions And Correct Answers
What medical term describes the surgical removal of the gallbladder?
cholecystectomy
What does "PHI" stand for? Expand the abbreviation.
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.
False
** A patient underwent brain surgery to treat bleeding in the brain from a
stroke. What PSHx would you record into the chart?
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?
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?
Yes
What medical term would best describe "the likely course or outcome of a
disease"?
Prognosis
Which section of the chart should you document when you hear the following
cue "what medical problems do you have"?
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?
Multiple complaints structure
Which of the following is NOT a purpose of HITECH?
- 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?
Hepatitis
For correct billing and reimbursement to go through, a counseling note requires
documentation of the following:
- Total time with the patient
- Percentage of time spent counseling
Questions And Correct Answers
What medical term describes the surgical removal of the gallbladder?
cholecystectomy
What does "PHI" stand for? Expand the abbreviation.
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.
False
** A patient underwent brain surgery to treat bleeding in the brain from a
stroke. What PSHx would you record into the chart?
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?
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?
Yes
What medical term would best describe "the likely course or outcome of a
disease"?
Prognosis
Which section of the chart should you document when you hear the following
cue "what medical problems do you have"?
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?
Multiple complaints structure
Which of the following is NOT a purpose of HITECH?
- 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?
Hepatitis
For correct billing and reimbursement to go through, a counseling note requires
documentation of the following:
- Total time with the patient
- Percentage of time spent counseling
