ScribeAmerica Outpatient Final: Practice
Questions & Answers
What will the scribe document for the outpatient visit? - ANSWER Important notes for
past medical records
History and Physical
Laboratory and radiology results
Physician Interpretation of XRs and EKGs
Assessment and Plan
Who is the first person to speak with the patient after he/she is placed in the room? -
ANSWER Nurse or MA
What are the meaningful use requirements the nurse or MA will obtain? - ANSWER
Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status
What does H&P abbreviate and who performs this evaluation? - ANSWER History and
Physical, physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER No, only
for a diagnostic visit
What information will be included in the patient's plan? - ANSWER Specialist follow-up,
instructions for lifestyle and preventative care, routine follow-up
The CBC shows anemia - ANSWER Results
The EKG shows NSR - ANSWER Results
The pt came to the clinic for chest pain - ANSWER HPI/ROS
The pt also stubbed his toe last week - ANSWER HPI/ROS
The pt is in no acute distress - ANSWER Physical Exam
The pt has suffered from HTN for many years - ANSWER PMHx
Thee is tenderness of the RUQ - ANSWER PE
The pt's mother has heart disease - ANSWER FHX
The diagnosis is upper respiratory infection - ANSWER Assessment
The pt will be prescribed penicillin today - ANSWER Plan
, What age would a family member's cardiac disease indicate an increased risk for similar
heart disease in the pt? - ANSWER <55 y/o
Who enforces meaningful use programs? - ANSWER Centers for Medicare and
Medicaid Services
What are three goals of the meaningful use program? - ANSWER 1. Safely integrate
technology into healthcare
2. Improve pt care coordination and track data trends
3. Empower patients through increased communication and transparency
Give five in-house lab examples - ANSWER 1. Pregnancy test
2. INR check
3. Finger-stick blood glucose
4. Rapid strep test
5. Urine dip
What is a V-Code? - ANSWER A billing code for preventative care
What does CPT stand for? - ANSWER Current Procedural Terminology
Name non-reimbursable complaints - ANSWER follow-up, check-up, lab results,
medication refill
True/False: A level 4 is a "comprehensive" E&M level? - ANSWER True
Why is it important to memorize the elements needed for a level 4? - ANSWER To
accurately reflect care given and to document to a high level and avoid E&M level
downgrading.
How many HPI elements are needed for a new patient at level 4? - ANSWER 4
elements
How many ROS elements are needed for established level 4? - ANSWER 2 elements
True/False: Each diagnosis should be followed-up with at least one line-item in the
plan? - ANSWER True
How is the plan formatted? - ANSWER Bullet points, numbers, or paragraph
The last bullet point in the plan should always be? - ANSWER the follow-up
Name three items you may include in a plan for Upper Respiratory Infection - ANSWER
Alternate Tylenol/Motrin for pain
Questions & Answers
What will the scribe document for the outpatient visit? - ANSWER Important notes for
past medical records
History and Physical
Laboratory and radiology results
Physician Interpretation of XRs and EKGs
Assessment and Plan
Who is the first person to speak with the patient after he/she is placed in the room? -
ANSWER Nurse or MA
What are the meaningful use requirements the nurse or MA will obtain? - ANSWER
Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status
What does H&P abbreviate and who performs this evaluation? - ANSWER History and
Physical, physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER No, only
for a diagnostic visit
What information will be included in the patient's plan? - ANSWER Specialist follow-up,
instructions for lifestyle and preventative care, routine follow-up
The CBC shows anemia - ANSWER Results
The EKG shows NSR - ANSWER Results
The pt came to the clinic for chest pain - ANSWER HPI/ROS
The pt also stubbed his toe last week - ANSWER HPI/ROS
The pt is in no acute distress - ANSWER Physical Exam
The pt has suffered from HTN for many years - ANSWER PMHx
Thee is tenderness of the RUQ - ANSWER PE
The pt's mother has heart disease - ANSWER FHX
The diagnosis is upper respiratory infection - ANSWER Assessment
The pt will be prescribed penicillin today - ANSWER Plan
, What age would a family member's cardiac disease indicate an increased risk for similar
heart disease in the pt? - ANSWER <55 y/o
Who enforces meaningful use programs? - ANSWER Centers for Medicare and
Medicaid Services
What are three goals of the meaningful use program? - ANSWER 1. Safely integrate
technology into healthcare
2. Improve pt care coordination and track data trends
3. Empower patients through increased communication and transparency
Give five in-house lab examples - ANSWER 1. Pregnancy test
2. INR check
3. Finger-stick blood glucose
4. Rapid strep test
5. Urine dip
What is a V-Code? - ANSWER A billing code for preventative care
What does CPT stand for? - ANSWER Current Procedural Terminology
Name non-reimbursable complaints - ANSWER follow-up, check-up, lab results,
medication refill
True/False: A level 4 is a "comprehensive" E&M level? - ANSWER True
Why is it important to memorize the elements needed for a level 4? - ANSWER To
accurately reflect care given and to document to a high level and avoid E&M level
downgrading.
How many HPI elements are needed for a new patient at level 4? - ANSWER 4
elements
How many ROS elements are needed for established level 4? - ANSWER 2 elements
True/False: Each diagnosis should be followed-up with at least one line-item in the
plan? - ANSWER True
How is the plan formatted? - ANSWER Bullet points, numbers, or paragraph
The last bullet point in the plan should always be? - ANSWER the follow-up
Name three items you may include in a plan for Upper Respiratory Infection - ANSWER
Alternate Tylenol/Motrin for pain
