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

- orders
- interpretations/results
treatments
- PE

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

maintain patient privacy and confidentiality

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

High risk

Patient with acute exacerbation of ESRD requiring emergency dialysis

Moderate risk

Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment

Low risk

patient with stable HTN and no other comorbities

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

PE

Which of the following are considered non-reimbursable chief complaints? (Select all that apply.)

Annual visit
follow up
checkup
medication refill
lab results

follow up
checkup
medication refill
lab results

Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.
What does "CP" stand for?

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.

False

What condition correctly describes "dangerous infection of the appendix"? (Do not use abbreviations. Remember, do not include any spaces before or after the term/phrase.)

appendicitis

An elderly male patient has a history of an enlarged prostate. What PMHx would you record into the chart? (Use the abbreviation form of the condition)

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. (Remember do not include spaces before or after your answer.

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. Remember, do not include any spaces before or after the term/phrase.)

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
- Prognosis/Plan

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

False

What is the medical term for "open heart surgery"? HINT: expand the abbreviation. (Remember: do not include any spaces before or after the term/phrase)

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? (Remember, do not include any spaces before or after the term/phrase.)

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).

- HPI
-ROS
-PHx
-PE
- Order/results
- assessment
- 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.

False

HEENT Throat

pharyngeal erythema

HEENT Ears

TM erythema

Cardiovascular

Tachycardia

Pulmonary

Rhonchi

Abdomen

Murphy's sign

Neurological

Alert and oriented x 4

A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? (HINT: Expand the medical abbreviation.) Remember, do not include any extra spaces before or after the term/phrase.

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.

False

What condition correctly describes "mini-stroke"? (Use the abbreviation form of the condition. Remember, do not include any spaces before or after the term/phrase.)

TIA

A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart? (HINT: one word only. Remember, do not include any spaces before or after the term/phrase.)

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)

bradycardia

What medical term can be used to describe "having multiple chronic conditions"? (Remember do not include spaces before or after your answer.)

comorbidity

A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (HINT: two words. Remember, do not include any spaces before or after the term/phrase.)

partial lobectomy

What can scribes in the clinic do to help accomplish MACRA and MIPS goals? (Select all that apply.)

- 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

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

A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

mastectomy

ICD code

codes for diagnosis

E&M code

Codes for reimbursement

HCC code

codes 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)

- Immunization status
- Second hand smoke exposure

What is the medical term for "pass-out"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase.)

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.

true

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? (select all that apply.)

- 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.)

oophorectomy

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)

- LOS5
-Established patient

HTN

low sodium diet, decrease EtOH intake, increase physical activity

DM

low carb diet, increase physical activity

HLD

low fat diet, increase physical activity

What are scribes NOT allowed to do? (select all applicable)

- 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.

False

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

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. Remember, do not include any spaces before or after the term/phrase.)

PNA

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

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.

False

What is the medical term for difficulty breathing? Hint: one word only.

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
Follow up with PCP
Follow up with specialist
Lifestyle recommendations
Preventative care instructions

What surgical procedure should be performed to diagnose CAD? (Remember do not include spaces before or after your answer.)

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

Why might it be important to document the presence of tears for pediatric or adult patients?

Indicates that the patient is hydrated

Your physician tells you the patient has bibasilar crackles on exam. In which organ system would you document this physical exam finding?

Respiratory

Name the section based on the following clues: "This subjective section (from the patient's perspective) is where you document the story of the chief complaint and what brought the patient to see the doctor." (Expand the abbreviation.)

HPI/ subjective

What chronic condition would require diagnosis through a lipid panel? Use the abbreviation form. (Remember do not include extra spaces before or after your answer)

HLD

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

What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT: two words. Expand abbreviations. (Remember do not include spaces before or after your answer.)

Diabetes mellitus

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 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