Scribe Final Exam Questions and
Answers
What ROS system would include dysphagia, the medical term for difficult or painful
swallowing? - Answer-Gastrointestinal
ENT
T/F. The ROS does not contain the CC and its associated symptoms because they are
already listed in the HPI. - Answer-T
T/F. Resolved problems may be deleted from the problem list. - Answer-F
A patient requires a heart bypass to treat a heart attack. What PSHx would you record
into the chart? - Answer-Coronary Artery Bypass Graft
A female patient has been pregnant four times in the past, is currently pregnant, and
has two children at home. Calculate the G, P and A, respectively. (Type your answer
using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no
spaces before or after the answer) - Answer-5,2,2
T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they
are included in the Problem List section. - Answer-F
T/F. It is acceptable to look up your own medical information while working in the clinic.
- Answer-F
What condition correctly describes "mini-stroke"? (abbrev) - Answer-TIA
A patient requires a "balloon" to treat a heart attack. What PSHx would you record into
the chart? - Answer-Angioplasty
Which of the following are considered to be cardiac risk factors for CP patients? (select
all that apply.) - Answer-PSHx of CABG, angioplasty and stent
HLD
DM
HTN
CAD
FHx of CAD <55 y/o
, tobacco use
What is the medical term for "slow heart rate"? - Answer-Bradycardia
What medical term can be used to describe "having multiple chronic conditions"? -
Answer-Comorbidity
A patient requires partial removal of the lung to treat lung cancer. What PSHx would you
record into the chart? (Two words) - Answer-partial lobectomy
What can scribes in the clinic do to help accomplish MACRA and MIPS goals? -
Answer-Document quality measures that are met by the physician during the visit.
Prompt the provider to perform a quality measure.
Use a tracking sheet to keep a track of patients that meet criteria for quality measures.
Determine which structure best fits the following Assessment.
"Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no
visible signs of tonsilar exudate. Rapid strep negative." - Answer-Brief summary
Which details are optional to include in a patient problem list? - Answer-Resolved date
Notes
Onset date
What condition correctly describes "A blood clot in the extremities"? (abbrev) - Answer-
DVT
A patient requires removal of the breast to treat breast cancer. What PSHx would you
record into the chart? - Answer-mastectomy
Match the following description with the corresponding code. - Answer-IDC code =
diagnosis
E&M = reimbursement
HCC = risk
Determine which structure best fits the following Assessment.
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in 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 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 attention.
Patient understands and agrees to be transferred to the ED." - Answer-comprehensive
summary
Answers
What ROS system would include dysphagia, the medical term for difficult or painful
swallowing? - Answer-Gastrointestinal
ENT
T/F. The ROS does not contain the CC and its associated symptoms because they are
already listed in the HPI. - Answer-T
T/F. Resolved problems may be deleted from the problem list. - Answer-F
A patient requires a heart bypass to treat a heart attack. What PSHx would you record
into the chart? - Answer-Coronary Artery Bypass Graft
A female patient has been pregnant four times in the past, is currently pregnant, and
has two children at home. Calculate the G, P and A, respectively. (Type your answer
using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no
spaces before or after the answer) - Answer-5,2,2
T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they
are included in the Problem List section. - Answer-F
T/F. It is acceptable to look up your own medical information while working in the clinic.
- Answer-F
What condition correctly describes "mini-stroke"? (abbrev) - Answer-TIA
A patient requires a "balloon" to treat a heart attack. What PSHx would you record into
the chart? - Answer-Angioplasty
Which of the following are considered to be cardiac risk factors for CP patients? (select
all that apply.) - Answer-PSHx of CABG, angioplasty and stent
HLD
DM
HTN
CAD
FHx of CAD <55 y/o
, tobacco use
What is the medical term for "slow heart rate"? - Answer-Bradycardia
What medical term can be used to describe "having multiple chronic conditions"? -
Answer-Comorbidity
A patient requires partial removal of the lung to treat lung cancer. What PSHx would you
record into the chart? (Two words) - Answer-partial lobectomy
What can scribes in the clinic do to help accomplish MACRA and MIPS goals? -
Answer-Document quality measures that are met by the physician during the visit.
Prompt the provider to perform a quality measure.
Use a tracking sheet to keep a track of patients that meet criteria for quality measures.
Determine which structure best fits the following Assessment.
"Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no
visible signs of tonsilar exudate. Rapid strep negative." - Answer-Brief summary
Which details are optional to include in a patient problem list? - Answer-Resolved date
Notes
Onset date
What condition correctly describes "A blood clot in the extremities"? (abbrev) - Answer-
DVT
A patient requires removal of the breast to treat breast cancer. What PSHx would you
record into the chart? - Answer-mastectomy
Match the following description with the corresponding code. - Answer-IDC code =
diagnosis
E&M = reimbursement
HCC = risk
Determine which structure best fits the following Assessment.
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in 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 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 attention.
Patient understands and agrees to be transferred to the ED." - Answer-comprehensive
summary
