TAUC Pre-Scribe U Like six different sets I combined together with
comprehensive questions and answers 2024/2025
What should be consistently documented in the Procedures section for billing
purposes?✔️✔️Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions?✔️✔️Document ll discussions
regarding any prescription medicine that the patient is already taking whenever it is relevant to
the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results?✔️✔️Whenever a patient shows you
outside labs or radiology results and asks you questions about them... Document: outside lab
results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you
include?✔️✔️Document any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed?✔️✔️When a pt is unable to
provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do?✔️✔️Do not select any of the three choices
in the top under "uses for coding"
,-uncomplicated
-systemic symptoms
-poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier?✔️✔️Choose the numbered choices from
the bottom section (top 4)
-Acute
-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as?✔️✔️Clinical not possible and you must include an
associated fracture dx
Should you document any refused procedures in the procedure note?✔️✔️yes
Can diagnosis modifiers be modified at a later time?✔️✔️Yes in the diagnosis screen by clicking
on "dx mod" button
Are charts coded by providers?✔️✔️No
What do you do if the common diagnosis list does not contain the diagnosis you need?✔️✔️You
can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
-Select a second more accurate diagnosis on the second screen
After you select the diagnosis, what must you specify in the next screen?✔️✔️Laterality, visit
number, further specification of anatomy
,What can you do if you are unable to locate the exact diagnosis?✔️✔️Rename the diagnosis by
typing in the rename bar
A plan is not created for every diagnosis... T/F✔️✔️FALSE
What does a plan contain?✔️✔️Advice
Referral options
Discharge instructions
RX
Every plan should include how many items/topics that are chosen under the advice?✔️✔️3
If a parent received an XR, CT, US during their visit, what should you do?✔️✔️Select lab and XR
sent with patient
-you then right click the bullet point and choose "nurse-todo list"
What does every referral include?✔️✔️A STL region associated with it.
How many referrals should you select in the same region as the TAUC location?✔️✔️2-4
What do you do if no options are listed?✔️✔️Click on referral options and choose the specialty
If you are unable to find discharge instruction in docutap's global database, what are you able to
do as an absolute last resort?✔️✔️Search for online resources
What must you do once you select discharge instruction?✔️✔️Right-click and select "nurse-todo
list"
, What must everyone who is seen for work comp have?✔️✔️-"See RTW": return to work form
-"Call made to employer-Bob"
-Must list their next follow up
If the Basic met panel w/ CK (metlyte) is ordered, do you need to order a BMP (ISTAT)?✔️✔️No
If a provider requests a CMP what do you order?✔️✔️ISTAT BMP & Liver panel
What does the uric acid panel (chem-13) include?✔️✔️Everything included in the liver panel plus
some tests included in the BMP
What should you double check when ordering medications?✔️✔️Drug, dose, route, and right
patients chart
What should you double check when ordering tetanus shot?✔️✔️Associated insurance
Which tetanus shot does medicare support vs all other insurances?✔️✔️Td = mediare
Tdap = all other insurances
What do you order if the pt needs a CT without IV fluids?✔️✔️IV catheter only
What do your order if the pt has been seen by the provider but still needs the initial assessment
performed by the tech?✔️✔️Initial vital
When do you order TB read only?✔️✔️When TB skin test was placed at another facility but read
here
How can EKG's be documented?✔️✔️Free-text or procedure note
comprehensive questions and answers 2024/2025
What should be consistently documented in the Procedures section for billing
purposes?✔️✔️Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions?✔️✔️Document ll discussions
regarding any prescription medicine that the patient is already taking whenever it is relevant to
the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results?✔️✔️Whenever a patient shows you
outside labs or radiology results and asks you questions about them... Document: outside lab
results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you
include?✔️✔️Document any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed?✔️✔️When a pt is unable to
provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do?✔️✔️Do not select any of the three choices
in the top under "uses for coding"
,-uncomplicated
-systemic symptoms
-poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier?✔️✔️Choose the numbered choices from
the bottom section (top 4)
-Acute
-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as?✔️✔️Clinical not possible and you must include an
associated fracture dx
Should you document any refused procedures in the procedure note?✔️✔️yes
Can diagnosis modifiers be modified at a later time?✔️✔️Yes in the diagnosis screen by clicking
on "dx mod" button
Are charts coded by providers?✔️✔️No
What do you do if the common diagnosis list does not contain the diagnosis you need?✔️✔️You
can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
-Select a second more accurate diagnosis on the second screen
After you select the diagnosis, what must you specify in the next screen?✔️✔️Laterality, visit
number, further specification of anatomy
,What can you do if you are unable to locate the exact diagnosis?✔️✔️Rename the diagnosis by
typing in the rename bar
A plan is not created for every diagnosis... T/F✔️✔️FALSE
What does a plan contain?✔️✔️Advice
Referral options
Discharge instructions
RX
Every plan should include how many items/topics that are chosen under the advice?✔️✔️3
If a parent received an XR, CT, US during their visit, what should you do?✔️✔️Select lab and XR
sent with patient
-you then right click the bullet point and choose "nurse-todo list"
What does every referral include?✔️✔️A STL region associated with it.
How many referrals should you select in the same region as the TAUC location?✔️✔️2-4
What do you do if no options are listed?✔️✔️Click on referral options and choose the specialty
If you are unable to find discharge instruction in docutap's global database, what are you able to
do as an absolute last resort?✔️✔️Search for online resources
What must you do once you select discharge instruction?✔️✔️Right-click and select "nurse-todo
list"
, What must everyone who is seen for work comp have?✔️✔️-"See RTW": return to work form
-"Call made to employer-Bob"
-Must list their next follow up
If the Basic met panel w/ CK (metlyte) is ordered, do you need to order a BMP (ISTAT)?✔️✔️No
If a provider requests a CMP what do you order?✔️✔️ISTAT BMP & Liver panel
What does the uric acid panel (chem-13) include?✔️✔️Everything included in the liver panel plus
some tests included in the BMP
What should you double check when ordering medications?✔️✔️Drug, dose, route, and right
patients chart
What should you double check when ordering tetanus shot?✔️✔️Associated insurance
Which tetanus shot does medicare support vs all other insurances?✔️✔️Td = mediare
Tdap = all other insurances
What do you order if the pt needs a CT without IV fluids?✔️✔️IV catheter only
What do your order if the pt has been seen by the provider but still needs the initial assessment
performed by the tech?✔️✔️Initial vital
When do you order TB read only?✔️✔️When TB skin test was placed at another facility but read
here
How can EKG's be documented?✔️✔️Free-text or procedure note
