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

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

F

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

***NOT Hemorrhagic CVA

Craniotomy for hemorrhagic CVA OR 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 Complaint structure

Which of the following is NOT a purpose of HITECH?

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 To require patient accountability in paying for their health care visit

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 the 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

Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a NEW patient:

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?

Lawsuit against you and the hospital Monetary fines to you and the hospital Scribe program cancellation Termination Prison time Violator is blacklisted from medical programs like Medical, PA, or NP school

What does HIPAA stand for? Expand the abbreviation.

Health Insurance Portability & Accountability Act

What chronic condition would require diagnosis through fasting blood glucose level or HbA1c?

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?

Interpretations/results orders treatments PE

HIPAA is a set of laws designed to

maintain patient privacy and confidentiality

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

PE

Matching the following description with the corresponding term.

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

Match the following scenario to the corresponding risk.

Moderate risk = asthmatic patient with acute acerbation that is resolved in office with nebulizer treatment High risk = patient with acute exerbation of ESRD requiring emergency dialysis Low risk = patient with stable HTN and no other comordibities

What chronic condition would require diagnosis through a lipid panel? (abbrev)

HLD

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

Medication refill lab results follow up check uo

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.

F

What condition correctly describes "dangerous infection of the appendix"?

appendicitis

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

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

Which of the following would be included in a Problem List?

Pyelonephritis, resolved Nephrolithiasis, stable

What condition correctly describes "heart attack"? (abbrev)

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?

TURP

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

Arrhythmia

Identify what details are included in the following Assessment. (Select all that apply.)

"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 HPI Diagnosis Prognosis/plan results

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

T/F. A scribe does NOT need to document a problem list for patients that are young, healthy, and without any medical problems.

F

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"? (abbrev)

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).

HPI ROS PHX PE Orders/Results Assessment Plan

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

Gastrointestinal ENT

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

F

T/F. Resolved problems may be deleted from the problem list.

F

A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart?

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

T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they are included in the Problem List section.

F

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

F

What condition correctly describes "mini-stroke"? (abbrev)

TIA

A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart?

Angioplasty

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

PSHx of CABG, angioplasty and stent HLD DM HTN CAD FHx of CAD <55 y/o tobacco use

What is the medical term for "slow heart rate"?

Bradycardia

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

Comorbidity

A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (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 tracking sheet 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

Which details are optional to include in a patient problem list?

Resolved date Notes Onset date

What condition correctly describes "A blood clot in the extremities"? (abbrev)

DVT

A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart?

mastectomy

Match the following description with the corresponding code.

IDC code = diagnosis E&M = reimbursement HCC = 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?

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?

relevant context severity modifying factors

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

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.)

Established pt LOS 5

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

HTN = low sodium diet, decrease EtOH, increase PA HLD = low fat diet, increase PA DM = low carb diet, increase PA

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

Perform clinical tasks (e.g. taking vitals) Transport patient specimens to the laboratory Authenticate the chart Touch patients Give CPR Give verbal orders Sign off on orders or prescriptions

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 Results 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 risk factors Information regarding prior evaluations Information regarding prior episodes

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 E&M

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

Impaired vision CRF MI CAD CHF

What condition correctly describes "A bacterial lung infection"? (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.

F

Match the description of the role with the team member

Scribe = Documents the patients visit on behalf of the physician Secretary = Answers phone calls, pages other specialists/doctors, and organizes the patient's paperwork Nurse/MA = records medical histories, symptoms, monitors the pt Mid level Provider = NP/PA that works under supervision of physician to diagnose and treat pt

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.)

Follow up with specialist Prescription for medication Prescription for diagnostic study Preventative care instructions Lifestyle recommendations Follow up with PCP

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