SCRIBEAMERICA OP FINAL EXAM TEST WITH VERIFIED ANSWERS
1. * What medical term describes the surgical cholecystectomy
removal of the gallbladder?
2. What does "PHI" stand for? Expand the abbre- Protected Health Informa-
viation. tion
3. T/F. Sharing information about a case with False
family is allowed, as long as you are scribing
with the physician assigned to the case.
4. ** A patient underwent brain surgery to treat craniotomy
bleeding in the brain from a stroke. What PSHx
would you record into the chart?
5. A patient's PCP is on vacation. The patient is Established
scheduled to see the NP who is covering for
the PCP during this time. The patient has nev-
er been seen by the NP before. Is this patient
considered a new patient or an established
patient?
6. A patient is diagnosed with back strain caused Yes
by heavy lifting. As part of the treatment,
the physician discusses 4-5 different back
stretching exercises that the patient can per-
form 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?
7. What medical term would best describe "the Prognosis
likely course or outcome of a disease"?
8. Which section of the chart should you docu- PHx
ment when you hear the following cue "what
medical problems do you have"?
9. You are writing an HPI for a patient who pre- Multiple complaints struc-
sented for hyperlipidemia management. In the ture
, SCRIBEAMERICA OP FINAL EXAM TEST WITH VERIFIED ANSWERS
middle of the visit, your patient also reports
having recently experienced urinary symp-
toms. Which HPI structure would be the best
to use in this scenario?
10. Which of the following is NOT a purpose of - To require patient ac-
HITECH? countability 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 afford-
ability for health insurance
plans by screening patient
health information
11. What medical term would describe a patient Hepatitis
with a history of infection or inflammation of
the liver?
12. For correct billing and reimbursement to go - Total time with the patient
through, a counseling note requires docu- - Percentage of time spent
mentation of the following: counseling
13. You are writing an HPI for a very complex Chronologic structure
patient who has had multiple recent hospital
admissions for lung cancer. Which HPI struc-
ture would be the best to use in this scenario?
14. Which of the following would be valid compli- MI
cations for CAD?
15. * 57 year old male patient presented with RLQ Yes, the HPI meets Level
abdominal pain, which began 5 days ago. He 4 billing criteria.
states that he was mowing the lawn when
the pain began. Patient reports he took OTC
Tylenol yesterday without relief. There has
been no nausea, vomiting or diarrhea.
1. * What medical term describes the surgical cholecystectomy
removal of the gallbladder?
2. What does "PHI" stand for? Expand the abbre- Protected Health Informa-
viation. tion
3. T/F. Sharing information about a case with False
family is allowed, as long as you are scribing
with the physician assigned to the case.
4. ** A patient underwent brain surgery to treat craniotomy
bleeding in the brain from a stroke. What PSHx
would you record into the chart?
5. A patient's PCP is on vacation. The patient is Established
scheduled to see the NP who is covering for
the PCP during this time. The patient has nev-
er been seen by the NP before. Is this patient
considered a new patient or an established
patient?
6. A patient is diagnosed with back strain caused Yes
by heavy lifting. As part of the treatment,
the physician discusses 4-5 different back
stretching exercises that the patient can per-
form 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?
7. What medical term would best describe "the Prognosis
likely course or outcome of a disease"?
8. Which section of the chart should you docu- PHx
ment when you hear the following cue "what
medical problems do you have"?
9. You are writing an HPI for a patient who pre- Multiple complaints struc-
sented for hyperlipidemia management. In the ture
, SCRIBEAMERICA OP FINAL EXAM TEST WITH VERIFIED ANSWERS
middle of the visit, your patient also reports
having recently experienced urinary symp-
toms. Which HPI structure would be the best
to use in this scenario?
10. Which of the following is NOT a purpose of - To require patient ac-
HITECH? countability 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 afford-
ability for health insurance
plans by screening patient
health information
11. What medical term would describe a patient Hepatitis
with a history of infection or inflammation of
the liver?
12. For correct billing and reimbursement to go - Total time with the patient
through, a counseling note requires docu- - Percentage of time spent
mentation of the following: counseling
13. You are writing an HPI for a very complex Chronologic structure
patient who has had multiple recent hospital
admissions for lung cancer. Which HPI struc-
ture would be the best to use in this scenario?
14. Which of the following would be valid compli- MI
cations for CAD?
15. * 57 year old male patient presented with RLQ Yes, the HPI meets Level
abdominal pain, which began 5 days ago. He 4 billing criteria.
states that he was mowing the lawn when
the pain began. Patient reports he took OTC
Tylenol yesterday without relief. There has
been no nausea, vomiting or diarrhea.
