OP final (w all qs)

* What medical term describes the surgical removal of the gallbladder?

cholecystectomy

What does "PHI" stand for? Expand the abbreviation.

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.

False

** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart?

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 been seen by the NP before. Is this patient considered a new patient or an established patient?

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?

Yes

What medical term would best describe "the likely course or outcome of a disease"?

Prognosis

Which section of the chart should you document when you hear the following cue "what medical problems do you have"?

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 would be the best to use in this scenario?

Multiple complaints structure

Which of the following is NOT a purpose of HITECH?

- 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?

Hepatitis

For correct billing and reimbursement to go through, a counseling note requires documentation of the following:

- Total time with the patient

- Percentage of time spent counseling

You are writing an HPI for a very complex patient who has had multiple recent hospital admissions for lung cancer. Which HPI structure would be the best to use in this scenario?

Chronologic structure

Which of the following would be valid complications for CAD?

MI

* 57 year old male patient presented with RLQ abdominal pain, which began 5 days ago. He 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.

Yes, the HPI meets Level 4 billing criteria.

What are the possible consequences of a HIPAA violation? (select all that apply)

- Termination

-Monetary fines to you and the hospital

- Prison time

-Lawsuit against you and the hospital

-Violator is blacklisted from medical programs like Medical, PA, or NP school

- Scribe program cancellation

What does HIPAA stand for? Expand the abbreviation. Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".

Health Insurance Portability and Accountability Act

What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT: two words. Expand abbreviations.

diabetes mellitus

A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not?

Yes, because the fever started soon after the cough

* Which of the following would be documented in the Objective section of the SOAP note? (select all that apply.)

- Orders

- Interpretations/results

- Treatments (that may involve medication or procedures)

- Physical exam

HIPAA is a set of laws designed to _______. (Select the best option.)

maintain patient privacy and confidentiality

What condition correctly describes "blood clot in the lungs"? (Use the abbreviation form of the condition)

PE

* MACRA

government healthcare initiative that focuses on quality of care to improve patient outcomes.

* MIPS

system of payment in which government funding is released if specific quality measures are tracked

Quality Measures

site specific health criteria that are tracked

High Risk

Moderate Risk

Low Risk

What chronic condition would require diagnosis through a lipid panel? Use the abbreviation form.

HLD

* Which of the following are considered non-reimbursable chief complaints?

- Follow-up

- Check-up

- Medication refill

- Lab results

CP

chest pain

T/F. A family friend was recently evaluated for IDDM and lost his paperwork and does not know what medications he should be taking at home. He asks you to look up his medical record when you go to your shift today, giving you verbal permission to access his information. In this scenario, it is justifiable for you to use your EMR login to look up the important patient information.

F

What condition correctly describes "dangerous infection of the appendix"? (Do not use abbreviations.

appendicitis

An elderly male patient has a history of an enlarged prostate. What PMHx would you record into the chart?

BPH

* A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic condition should be included in their diagnosis today? Expand the abbreviation.

Coronary Artery Disease

A patient states that he has been having abdominal pain for the last three days, and it varies between mild and severe. Which of the following would best describe the Timing?

waxing and waning

The patient reports a tenderness in their right upper abdomen that began 2 weeks ago. Based on that information, do you document RUQ tenderness under the physical exam?

No

* What condition correctly describes "heart attack"? (Use the abbreviated form of the condition)

MI

* An elderly male patient has a history of an enlarged prostate and has undergone surgery to treat his condition. What PSHx would you record into the chart? Use the abbreviation form.

TURP

What medical term is used to describe the symptom of a patient's heart beating rapidly, irregularly, or forcibly?

palpitations

* "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED."

- Age and Sex

- PHx, if relevant

- Diagnosis

- Results

- HPI ( first two sentences)

- Prognosis/Plan

T/F. All symptoms documented in the ROS are also documented in the HPI.

F

What is the medical term for "open heart surgery"? HINT: expand the abbreviation.

Coronary Artery Bypass Graft

Identify which of these PE systems contains contradictory findings:

Respiratory: No respiratory distress, tachypnea, lungs are clear to auscultation bilaterally

If a patient signs a waiver giving you permission to capture photo of their unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo? (Select the best option.)

Yes because the phone is not an approved hospital device and it is not encrypted.

What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"? HINT: Use the abbreviation form of the condition.

CAD

An elderly female patient has a history of brittle bone disease and is at risk for developing bone fractures. What PMHx would you record into the chart?

osteoporosis

What medical term is used to describe the physician examining the patient by touch?

palpation

Organize the parts of the chart in order from top (1) to bottom (7).

1. HPI

2. ROS

3. PHx

4. PE

5. Orders/Results

6. Assessment

7. Plan

What ROS system would include dysphagia, the medical term for difficult or painful swallowing?

ENT

T/F. The ROS does not contain the CC and its associated symptoms because they are already listed in the HPI.

F (bc anything in hpi will be in ros)

48

* A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? (HINT: Expand the medical abbreviation.)

coronary artery bypass graft

A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer)

5,2,2

What body system would the exam finding PERRL be documented in?

Eyes

T/F. It is acceptable to look up your own medical information while working in the clinic.

F

* What condition correctly describes "mini-stroke"? (Use the abbreviation form of the condition.)

TIA

A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart? (HINT: one word only.)

angioplasty

Which of the following are considered to be cardiac risk factors for CP patients? (select all that apply)

- HTN

- HLD

- Family hx of

CAD

What is the medical term for "slow heart rate"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase)

bradycaridia

What medical term can be used to describe "having multiple chronic conditions"?

comorbidities

A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (HINT: two words)

partial lobectomy

What can scribes in the clinic do to help accomplish MACRA and MIPS goals?

- Document quality measures that are met by the physician during the visit.

- Prompt the provider to perform a quality measure.

- Use a trackingsheet to keep a track of patients that meet criteria for quality measures.

Determine which structure best fits the following Assessment.

"Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no visible signs of tonsilar exudate. Rapid strep negative."

Brief summary

You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "The pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam?

- wrist

2+ radial pulse

- top of foot

2+ DP pulse

- neck

2+ carotid pulse

- back of foot

2+ PT pulse

What condition correctly describes "A blood clot in the extremities"? (HINT: Use the abbreviation form of the condition)

DVT

1) ICD code

2) E&M code

3) HCC code

1) codes for diagnosis

2) codes for reimbursement

3) code for risk

* Determine which structure best fits the following Assessment.

"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED."

Comprehensive summary

What FHx/SHx information is usually asked for pediatric patients? (Select all that apply)

- Second hand smoke exposure

- Immunization status

What is the medical term for "pass-out"?

Syncope

Which symptom(s) would a patient most likely present with if they had HLD? (Select all that apply

Asymptomatic

T/F. Scribes should complete all charts by entering a scribe attestation before leaving the shift.

T

A 45 year old male presents to the clinic with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. He denies any accompanying dyspnea or diaphoresis. What elements are missing?

- Severity

- Modifying factor

- Relevant context

A female patient underwent surgery to have her ovary removed. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

oopherectomy

A patient comes into the clinic for a well woman exam. What type of clinic visit is this?

Health management visit

A patient has an E&M code of 99215. What information does this code give? (Select all that apply)

- Established pt

- LOS 5

Match the chronic condition with it's corresponding nonpharmacological treatment:

1) HTN

2) DM

3) HLD

1) Low sodium diet, decrease EtOH intake, increase physical activity

2)low carb diet, increase phy. activity

3) low fat diet, incr. phy. activity

What are scribes NOT allowed to do?

- Touch patients

- Perform clinical tasks (e.g. taking vitals)

- Sign off on orders or prescriptions

- Authenticate the chart

- Transport patient specimens to the laboratory

- Give verbal orders

- Give CPR

T/F. One of your co-workers is having difficulty printing a CT report and asks you to look up the report for them. You can look up the report as long as you do not read it.

F

A female patient underwent surgery to have an ovary and fallopian tube removed. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

salpingo-oophorectomy

* A modifier code usually gives information about which type of code?

Procedure code

What three details should be included in a sentence summarizing results in the Assessment Section? (Select all that apply.)

- Name of the test

- Result of the test

- Reason for why was the test ordered

Which of the following details could be categorized as the HPI element context? (Select all that apply)

- Information regarding prior episodes

- Information regarding prior evaluations

- Information regarding risk factors (bp, medication compliance)

Which symptom(s) would a patient most likely present with if they had asthma? (Select all that apply)

Dyspnea

A patient comes into the clinic for 3 weeks of a productive cough. What type of clinic visit is this?

Diagnostic visit

Which two codes should always be included on every superbill?

- ICD code

- E&M code

* Which of the following would be valid complications for HTN? (Select all that apply.)

- CHF

- MI

- CRF

- Impaired vision

- CAD

* What condition correctly describes "A bacterial lung infection"? (HINT: Use the abbreviation form of the condition.)

PNA

A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart?

Hysterectomy

T/F. The physician asks Scribe Sally to hold a patient's arm down so that she can finish suturing the patient. Sally is allowed to help because she is not interfering with the procedure.

F

88

What is the medical term for difficulty breathing?

Dyspnea

What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"?

Genitourinary

Which of the following information should you be including in the plan section when documenting? (Select all that apply.)

- Prescription for medication

- Prescription for diagnostic study (referral)

- Follow up with PCP

- Follow up with specialist

- Lifestyle recommendations

- Preventative care instructions

** What surgical procedure should be performed to diagnose CAD?

Cardiac catheterization

Can you document both "Clear breath sounds bilaterally" and "rhonchi in the right base"? Why or why not?

No, because they contradict each other

Murphy's sign is examined in which organ system?

Abdomen

A positive straight-leg-raise may indicate herniated discs. Which organ system should this PE finding be documented in

back

Identify which of these selections contain contradictory physical exam findings.

Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact.

When should the word "lethargy" be documented on the chart?

Only when the physician explicitly tells you to do so