SCRIBE FINAL EXAM ED QUESTIONS
AND ANSWERS
Can you share the patient's chart with all nurses working in the hospital? - Answer-No,
but you may discuss the patient's case with the hospital personal (Tech, RN, MD,
consulting team, case manager, etc.) directly treating the patient.
Is it acceptable to use the physician's charting account to enter the EKG interpretation
once the physician provided approval? - Answer-No, all chart done by a scribe must be
completed in the scribe's charting account.
Does the following Past Hx meet level V billing requirements: HTN, previous CVA in
2008 with residual LLE weakness, DM diagnosed at age 47, CABG x2 in 2011, and
Tonsillectomy. - Answer-No. This is only medical and surgical history which are
considered ONE element.
Give 5 examples if PHI. - Answer-Patient's Name, DOB, SSN, address, email,
insurance information, phone number.
How many elements are required for a level V ROS with and without the "All Systems
Negative" phrase? - Answer-2 with, 10 without.
True or false: The "All systems negative" phrase is used for all chart. - Answer-False.
Including the phrase is the physician's preference AND also never used on patient's
unable to complete the interview (advanced dementia, AMS, unresponsive, etc.)
Name 4 common events that are timestamped in the chart. - Answer-The moment the
provider walks into the patient's room for the initial evaluation, medication orders,
consults, procedure start/end times, disposition times.
Describe a scenario where the R/B/A discussion could occur. - Answer-Before
procedure such as the lumbar puncture, conscious sedation, cardioversion, receiving
tPA, starting/stopping blood thinners, CT's for children.
List 2 examples of a "unique exam identifier". - Answer-Scars, tattoos, amputations, G-
tubes, trach scars, "zipper" sternotomy scar, birthmarks.
How many elements are included in this HPI: Ariana Venti is a 24 y/o female presenting
to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over
the central chest and worse when leaning forward. - Answer-4 total= billing at level 5!
1. Sharp- quality
2. 4 hours ago, sudden- onset
3. Central- location
4. Leaning forward- modifying factor (worsening factor)
,-ectomy - Answer-Surgical removal of...
-ostomy - Answer-Opening; orifice
Masto- - Answer-Breast
-itis - Answer-Inflammation
-lithiasis - Answer-Stone; calculi
Sub- - Answer-Below; beneath
-osteo - Answer-Bone
hyper- - Answer-Over; high
hypo- - Answer-Below; low
poly- - Answer-Much; many
Ad- - Answer-Toward
Ab- - Answer-Away from
-rrhaphy - Answer-"Suturing in place"
Chief Complaint: - Answer-The main reason for the pts ED visit
Medical Decision Making: - Answer-The physician's thought process
Pain vs. Tenderness: - Answer-Patient's feeling vs. Physician's assessment
Distress: - Answer-The doctor's judgement of discomfort
Baseline: - Answer-An individual's normal state of being
Auscultation: - Answer-Listening with a stethoscope
Palpation: - Answer-The act of pressing on an area (by the doctor)
Inpatient: - Answer-Admitted to the hospital overnight
Outpatient: - Answer-Seen and sent home the same day
The Physical Exam and the ED Course are ... - Answer-Objective Evaluations
,The HPI and the ROS are... - Answer-Subjective Complaints
DDx: - Answer-Differential Dx- Based on the H&P the physician generates a list of
things that may be causing the pt's subjective Sx. Then the doctor places orders to "rule
out" each differential
Final Dx: - Answer-By using Medical Decision Making (MDM) the physician reviews
specific results that can rule out DDx ( Differential Diagnosis) to reach the final Dx
High blood pressure .. - Answer-HTN; Hypertension
High cholesterol .. - Answer-HLD; Hyperlipidemia
Thyroid problem .. - Answer-Usually Hypothyroidism, sometimes Hyperthyroidism
Diabetes .. - Answer-DM; Diabetes Mellitus
"I only take pills for my diabetes" - Answer-NIDDM
"I take shots (insulin) for my diabetes" - Answer-IDDM
CARDIO PMHX:
Heart Dz - Answer-YOU WRITE:
Usually CAD
CARDIO PMHX:
Heart attack - Answer-YOU WRITE:
MI
CARDIO PMHX:
Heart Failure - Answer-YOU WRITE:
CHF
CARDIO PMHX:
Irregular Heartbeat - Answer-YOU WRITE:
Arrhythmia, A-fib
CARDIO PMHX:
Murmur - Answer-YOU WRITE:
Heart Murmur
CARDIO PMHX:
Episodes of abnormally fast/racing heartbeat - Answer-YOU WRITE:
Arrhythmia, Supraventricular Tachycardia (SVT)
, PULMONARY PMHX:
Asthma - Answer-YOU WRITE:
Asthma
PULMONARY PMHX:
Emphysema/ Chronic Bronchitis - Answer-YOU WRITE:
COPD
PULMONARY PMHX:
Blood clot in the lung - Answer-YOU WRITE:
PE (Pulmonary Embolism)
PULMONARY PMHX:
Pneumonia - Answer-YOU WRITE:
Pneumonia (PNA)
GI PMHX:
Reflux - Answer-YOU WRITE:
Gastroesophageal Reflux Dz (GERD)
GI PMHX:
Ulcer - Answer-YOU WRITE:
Gastric Ulcer or Peptic Ulcer Dz
GI PMHX:
Pancreatitis - Answer-YOU WRITE:
Pancreatitis
GI PMHX:
Hepatitis - Answer-YOU WRITE:
Hepatitis
GI PMHX:
Diverticulitis - Answer-YOU WRITE:
Diverticulitis
GI PMHX:
Croh's/UC - Answer-YOU WRITE:
Crohn's Dz or Ulcerative Colitis
GI PMHX:
Irritable Bowel - Answer-YOU WRITE:
IBS (Irritable Bowel Syndrome)
GA PMHX:
Bladder Infection - Answer-YOU WRITE:
AND ANSWERS
Can you share the patient's chart with all nurses working in the hospital? - Answer-No,
but you may discuss the patient's case with the hospital personal (Tech, RN, MD,
consulting team, case manager, etc.) directly treating the patient.
Is it acceptable to use the physician's charting account to enter the EKG interpretation
once the physician provided approval? - Answer-No, all chart done by a scribe must be
completed in the scribe's charting account.
Does the following Past Hx meet level V billing requirements: HTN, previous CVA in
2008 with residual LLE weakness, DM diagnosed at age 47, CABG x2 in 2011, and
Tonsillectomy. - Answer-No. This is only medical and surgical history which are
considered ONE element.
Give 5 examples if PHI. - Answer-Patient's Name, DOB, SSN, address, email,
insurance information, phone number.
How many elements are required for a level V ROS with and without the "All Systems
Negative" phrase? - Answer-2 with, 10 without.
True or false: The "All systems negative" phrase is used for all chart. - Answer-False.
Including the phrase is the physician's preference AND also never used on patient's
unable to complete the interview (advanced dementia, AMS, unresponsive, etc.)
Name 4 common events that are timestamped in the chart. - Answer-The moment the
provider walks into the patient's room for the initial evaluation, medication orders,
consults, procedure start/end times, disposition times.
Describe a scenario where the R/B/A discussion could occur. - Answer-Before
procedure such as the lumbar puncture, conscious sedation, cardioversion, receiving
tPA, starting/stopping blood thinners, CT's for children.
List 2 examples of a "unique exam identifier". - Answer-Scars, tattoos, amputations, G-
tubes, trach scars, "zipper" sternotomy scar, birthmarks.
How many elements are included in this HPI: Ariana Venti is a 24 y/o female presenting
to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over
the central chest and worse when leaning forward. - Answer-4 total= billing at level 5!
1. Sharp- quality
2. 4 hours ago, sudden- onset
3. Central- location
4. Leaning forward- modifying factor (worsening factor)
,-ectomy - Answer-Surgical removal of...
-ostomy - Answer-Opening; orifice
Masto- - Answer-Breast
-itis - Answer-Inflammation
-lithiasis - Answer-Stone; calculi
Sub- - Answer-Below; beneath
-osteo - Answer-Bone
hyper- - Answer-Over; high
hypo- - Answer-Below; low
poly- - Answer-Much; many
Ad- - Answer-Toward
Ab- - Answer-Away from
-rrhaphy - Answer-"Suturing in place"
Chief Complaint: - Answer-The main reason for the pts ED visit
Medical Decision Making: - Answer-The physician's thought process
Pain vs. Tenderness: - Answer-Patient's feeling vs. Physician's assessment
Distress: - Answer-The doctor's judgement of discomfort
Baseline: - Answer-An individual's normal state of being
Auscultation: - Answer-Listening with a stethoscope
Palpation: - Answer-The act of pressing on an area (by the doctor)
Inpatient: - Answer-Admitted to the hospital overnight
Outpatient: - Answer-Seen and sent home the same day
The Physical Exam and the ED Course are ... - Answer-Objective Evaluations
,The HPI and the ROS are... - Answer-Subjective Complaints
DDx: - Answer-Differential Dx- Based on the H&P the physician generates a list of
things that may be causing the pt's subjective Sx. Then the doctor places orders to "rule
out" each differential
Final Dx: - Answer-By using Medical Decision Making (MDM) the physician reviews
specific results that can rule out DDx ( Differential Diagnosis) to reach the final Dx
High blood pressure .. - Answer-HTN; Hypertension
High cholesterol .. - Answer-HLD; Hyperlipidemia
Thyroid problem .. - Answer-Usually Hypothyroidism, sometimes Hyperthyroidism
Diabetes .. - Answer-DM; Diabetes Mellitus
"I only take pills for my diabetes" - Answer-NIDDM
"I take shots (insulin) for my diabetes" - Answer-IDDM
CARDIO PMHX:
Heart Dz - Answer-YOU WRITE:
Usually CAD
CARDIO PMHX:
Heart attack - Answer-YOU WRITE:
MI
CARDIO PMHX:
Heart Failure - Answer-YOU WRITE:
CHF
CARDIO PMHX:
Irregular Heartbeat - Answer-YOU WRITE:
Arrhythmia, A-fib
CARDIO PMHX:
Murmur - Answer-YOU WRITE:
Heart Murmur
CARDIO PMHX:
Episodes of abnormally fast/racing heartbeat - Answer-YOU WRITE:
Arrhythmia, Supraventricular Tachycardia (SVT)
, PULMONARY PMHX:
Asthma - Answer-YOU WRITE:
Asthma
PULMONARY PMHX:
Emphysema/ Chronic Bronchitis - Answer-YOU WRITE:
COPD
PULMONARY PMHX:
Blood clot in the lung - Answer-YOU WRITE:
PE (Pulmonary Embolism)
PULMONARY PMHX:
Pneumonia - Answer-YOU WRITE:
Pneumonia (PNA)
GI PMHX:
Reflux - Answer-YOU WRITE:
Gastroesophageal Reflux Dz (GERD)
GI PMHX:
Ulcer - Answer-YOU WRITE:
Gastric Ulcer or Peptic Ulcer Dz
GI PMHX:
Pancreatitis - Answer-YOU WRITE:
Pancreatitis
GI PMHX:
Hepatitis - Answer-YOU WRITE:
Hepatitis
GI PMHX:
Diverticulitis - Answer-YOU WRITE:
Diverticulitis
GI PMHX:
Croh's/UC - Answer-YOU WRITE:
Crohn's Dz or Ulcerative Colitis
GI PMHX:
Irritable Bowel - Answer-YOU WRITE:
IBS (Irritable Bowel Syndrome)
GA PMHX:
Bladder Infection - Answer-YOU WRITE:
