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ScribeAmerica OP Final Questions with Answers (100%
Correct Answers)
* What medical term describes the surgical removal of the gallbladder?
Answer: cholecystectomy
What does "PHI" stand for? Expand the abbreviation. Answer:
Protected Health Information
T/F. Sharing information about a case with family is allowed, as long
as you are scribing with the physician assigned to the case. Answer:
False
** A patient underwent brain surgery to treat bleeding in the brain
from a stroke. What PSHx would you record into the chart? Answer:
craniotomy
A patient's PCP is on vacation. The patient is scheduled to see the NP
who is covering for the PCP during this time. The patient has never
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,2
been seen by the NP before. Is this patient considered a new patient or
an established patient? Answer: Established
A patient is diagnosed with back strain caused by heavy lifting. As
part of the treatment, the physician discusses 4-5 different back
stretching exercises that the patient can perform 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? Answer: Yes
What medical term would best describe "the likely course or outcome
of a disease"? Answer: Prognosis
Which section of the chart should you document when you hear the
following cue "what medical problems do you have"? Answer: PHx
You are writing an HPI for a patient who presented for hyperlipidemia
management. In the middle of the visit, your patient also reports
having recently experienced urinary symptoms. Which HPI structure
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, 3
would be the best to use in this scenario? Answer: Multiple
complaints structure
Which of the following is NOT a purpose of HITECH? Answer: - To
require patient accountability 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 affordability for health
insurance plans by screening patient health information
What medical term would describe a patient with a history of infection
or inflammation of the liver? Answer: Hepatitis
For correct billing and reimbursement to go through, a counseling note
requires documentation of the following: Answer: - Total time with
the patient
- Percentage of time spent counseling
© 2025 All rights reserved
ScribeAmerica OP Final Questions with Answers (100%
Correct Answers)
* What medical term describes the surgical removal of the gallbladder?
Answer: cholecystectomy
What does "PHI" stand for? Expand the abbreviation. Answer:
Protected Health Information
T/F. Sharing information about a case with family is allowed, as long
as you are scribing with the physician assigned to the case. Answer:
False
** A patient underwent brain surgery to treat bleeding in the brain
from a stroke. What PSHx would you record into the chart? Answer:
craniotomy
A patient's PCP is on vacation. The patient is scheduled to see the NP
who is covering for the PCP during this time. The patient has never
© 2025 All rights reserved
,2
been seen by the NP before. Is this patient considered a new patient or
an established patient? Answer: Established
A patient is diagnosed with back strain caused by heavy lifting. As
part of the treatment, the physician discusses 4-5 different back
stretching exercises that the patient can perform 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? Answer: Yes
What medical term would best describe "the likely course or outcome
of a disease"? Answer: Prognosis
Which section of the chart should you document when you hear the
following cue "what medical problems do you have"? Answer: PHx
You are writing an HPI for a patient who presented for hyperlipidemia
management. In the middle of the visit, your patient also reports
having recently experienced urinary symptoms. Which HPI structure
© 2025 All rights reserved
, 3
would be the best to use in this scenario? Answer: Multiple
complaints structure
Which of the following is NOT a purpose of HITECH? Answer: - To
require patient accountability 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 affordability for health
insurance plans by screening patient health information
What medical term would describe a patient with a history of infection
or inflammation of the liver? Answer: Hepatitis
For correct billing and reimbursement to go through, a counseling note
requires documentation of the following: Answer: - Total time with
the patient
- Percentage of time spent counseling
© 2025 All rights reserved
