SCRIBE FINAL EXAM QUESTIONS AND
ANSWERS
What does TURP stand for? - Answer-transurethral resection of the prostate
which of the following is correctly matched? - Answer-BKA - below knee amputation
The HPI should provide context to acute symptoms only - Answer-false
Which two elements should be written first in a HPI? - Answer-Chief Complaint - Patient
Identification
You can limit an HPI when a patient does not provide relevant information? - Answer-
False
The HPI contains what type of information? - Answer-subjective
You can infer information from a patients story and add it to their documentation. -
Answer-False
The HPI contains objective information. - Answer-False
If a family member is noting information, you do not need to specify. - Answer-False
Which of the following is correctly matched? - Answer-History of Present Illness -
subejctive
Which of the following is correctly matched? - Answer-tachycardia - rapid heart rate
What is the medical terminology for vomiting blood? - Answer-hematemesis
Onset and location are two important elements that are important for ICD-10 coding. -
Answer-True
Which of the following is not one of the 11 elements of the HPI? - Answer-History
If you are unsure how to work a patient response or statement, what should you do? -
Answer-put it in quotes
It is important to include specific ______ when documenting symptoms, follow ups or
future appointments. - Answer-Dates
What should never be included in a HPI unless quoted directly? - Answer-Self
Diagnoses
, it is important to use "patient states" for the beginning of each sentence to be
consistent. - Answer-False
If a patient has previously been seen for similar symptoms ,do you need to note that in
the HPI? why? - Answer-Yes, important for ICD-10 coding
chronological order is not important when writing an HPI - Answer-False
Select the correct answers to fill in the blanks. As a scribe it is your job to ______
document patient ______ to physician questions. - Answer-Always, Answers
What is the medical terminology for removal of the liver? - Answer-hepatectomy
What part of the chart is a head to the checklist of patient symptoms? - Answer-Review
of Systems
if a symptom is not related to the patients cheif complaint it does not need to be
included in Ros - Answer-False
What is the difference between HPI and ROS - Answer-HPI: relevant to CC and patient
encounter; ROS: checklist of symptoms
The ROS supports the HPI infromation - Answer-True
ROS contains what type of informations - Answer-Subjective
If a patient complains of toe pain but their chief complaint is chest pain, does it need to
be included in the HPI? - Answer-No, not related to CC.
If you must limit the ROS due to extenuation circumstances you must make a note of it.
- Answer-True
Scribes can infer patients have severe abdominal tenderness because the patient
complains of 10/10 abdominal pain. - Answer-False
A patient presents complaining of abdominal pain. You write in the HPI that the patient
complains of abdominal pain, and also not this in the ROS. Your physician tells you that
the abdomen is non-tender. This is a contradiction. - Answer-False
What tare the 5 vital signs? - Answer-HR, BP, SpO2, RR, Temp
Which of the following is the correct meaning of the abbreviation HIPAA - Answer-
Health insurance probability and accountability act
What is PHI? - Answer-protected health information
ANSWERS
What does TURP stand for? - Answer-transurethral resection of the prostate
which of the following is correctly matched? - Answer-BKA - below knee amputation
The HPI should provide context to acute symptoms only - Answer-false
Which two elements should be written first in a HPI? - Answer-Chief Complaint - Patient
Identification
You can limit an HPI when a patient does not provide relevant information? - Answer-
False
The HPI contains what type of information? - Answer-subjective
You can infer information from a patients story and add it to their documentation. -
Answer-False
The HPI contains objective information. - Answer-False
If a family member is noting information, you do not need to specify. - Answer-False
Which of the following is correctly matched? - Answer-History of Present Illness -
subejctive
Which of the following is correctly matched? - Answer-tachycardia - rapid heart rate
What is the medical terminology for vomiting blood? - Answer-hematemesis
Onset and location are two important elements that are important for ICD-10 coding. -
Answer-True
Which of the following is not one of the 11 elements of the HPI? - Answer-History
If you are unsure how to work a patient response or statement, what should you do? -
Answer-put it in quotes
It is important to include specific ______ when documenting symptoms, follow ups or
future appointments. - Answer-Dates
What should never be included in a HPI unless quoted directly? - Answer-Self
Diagnoses
, it is important to use "patient states" for the beginning of each sentence to be
consistent. - Answer-False
If a patient has previously been seen for similar symptoms ,do you need to note that in
the HPI? why? - Answer-Yes, important for ICD-10 coding
chronological order is not important when writing an HPI - Answer-False
Select the correct answers to fill in the blanks. As a scribe it is your job to ______
document patient ______ to physician questions. - Answer-Always, Answers
What is the medical terminology for removal of the liver? - Answer-hepatectomy
What part of the chart is a head to the checklist of patient symptoms? - Answer-Review
of Systems
if a symptom is not related to the patients cheif complaint it does not need to be
included in Ros - Answer-False
What is the difference between HPI and ROS - Answer-HPI: relevant to CC and patient
encounter; ROS: checklist of symptoms
The ROS supports the HPI infromation - Answer-True
ROS contains what type of informations - Answer-Subjective
If a patient complains of toe pain but their chief complaint is chest pain, does it need to
be included in the HPI? - Answer-No, not related to CC.
If you must limit the ROS due to extenuation circumstances you must make a note of it.
- Answer-True
Scribes can infer patients have severe abdominal tenderness because the patient
complains of 10/10 abdominal pain. - Answer-False
A patient presents complaining of abdominal pain. You write in the HPI that the patient
complains of abdominal pain, and also not this in the ROS. Your physician tells you that
the abdomen is non-tender. This is a contradiction. - Answer-False
What tare the 5 vital signs? - Answer-HR, BP, SpO2, RR, Temp
Which of the following is the correct meaning of the abbreviation HIPAA - Answer-
Health insurance probability and accountability act
What is PHI? - Answer-protected health information
