scirbe u 5

What medical term describes the surgical removal of the gallbladder?

cholecystectomy

What does "PHI" stand for?

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 in the chart?

Craniotomy

A patients 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. 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 best to use in this scenario?

Multiple complaints structure?

Which of the following is not a purpose of HITECH?

-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. -To require government accountability on health insurance plans available in the market place. -To require encryption when using technology to transmit patient related 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

-Patient arrival time -percentage of time spent counseling -percentage of time spent with physician vs with nurse/MA -total time with the patient -patient departure times

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?

select all

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

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

Diabetes

A patient states she 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 -Physical exam -Orders -Treatments

HIPAA is a set of laws designed to _________

maintain patient privacy and confidentiality

What condition correctly describes "blood clot in lungs"

pulmonary embolism, PE

Matching the following description with corresponding term.

MACRA- government health care initiative that focuses on quality of car to improve patient outcomes. MIPS- system of payment in which government finding 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.

Low risk- patient with stable htn and no other comorbities High risk- patient with acute exerbation of ESRD requiring emergency dialysis Moderate risk- asthmatic patient with accute acerbation that is resolve in office with nebulizer treatment

What chronic condition would require diagnosis through a lipid panel?

HLD

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

-medication refill -check up -lab results

Expand the following medical abbreviation. 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"?

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?

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?

-Family hx of renal cancer -Hx of renal stone extraction

What condition correctly describes "heart attack"?

myocardial infarction

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?

Palpitation

Identify what details are included in 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 one day okay. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may expect death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to ED.

-age and sex -prognosis/plan -differential diagnosis -PHx, if relevant -HPI

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

False

What is the medical term for "open heart surgery"?

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.

False

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?

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"?

CAD

An elderly female patient has a history of brittle bone disease and is at risk for developing bone fracture. 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 from top to bottom

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.

False

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

False

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,A

5,2,2

T/F. Active diagnoses do not have to be includes in the PHx section of the chart if they are included in the problem list section.

False

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

False

What condition correctly describes "mini-stroke"?

TIA

Which of the following is considered to be cardiac risk factors for CP patients?

-Family hx of CAD <55 y/o -PSHx of CABG, angioplasty and stent -CAD -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?

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. -use a trackingsheet to keep track of patients that meet criteria for quality measures -prompt the provider to perform a quality measure

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?

-note -status -resolved date

What condition correctly describes "a blood clot in the extremities"?

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.

-LCD code: codes for diagnosis -E&M: codes for reimbursement -HCC code: codes for risk

Determine which structure best fits the following assessment

Patient is 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. Creatine and BUN elevated and worsening compared to the last visit 3 weeks ago. Patient recommened 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?

-Immunization status -Second hand smoke exposure

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

syncope

Which symptoms 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.

True

A 45 year old make presents to the clinic with a constant, ripping, tearing pain to this 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 -relevant context -modifying factor

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?

Healthy management visit

A patient has an E&M code of 99215. What information does this code give?

Established patient

Match the chronic condition with its corresponding nonpharmacological treatment.

HLD- low fat diet, increase physical activity DM- low carb diet, increase physical activity HTN- low sodium diet, decrease EtOH intake, increase physical activity

What are scribes NOT allowed to do?

-touch patients -perform clinical tests -sign off on orders or prescriptions -give verbal orders -authenticate the chart -give CPR -transport patient specimens to the laboratory

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?

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?

-name of the test -results of the test -reason for why the test was ordered

Which of the following details could be categorized as the HPI element context?

-information regarding risk factors -information regarding prior evaluations -information regarding prior episodes

Which symptoms would a patient most likely present with if they has asthma?

dyspnea

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

Diagnostic

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?

-CRF -CHF -CAD -impaired vision -MI

What condition correctly describes "a bacterial lung infection"

Pneumonia

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 patients arm down so that he can finish suturing the patient. Sally is allowed to help because she is not interfering with the procedure.

False

Match the description of the ratio with the team member.

-Midlevel Provider: Nurse practitioner or physician assistant that works under the supervision of a physician to diagnose and treat patients. -Nurse/MA: Records medical histories, monitors the patient, starts IVs, administers medications, and assists with procedures. -Scribe: document the patients visit on behalf of the physician -Secretary: Answers phone calls, pages other specialists/doctors, and organizes the patient's paperwork.

What is the medical term for difficulty breathing?

dyspnea

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

Genitourinary

Which of the following information should be included in the plan section when documenting?

-prescription for medication -prescription for diagnostic study -follow up with PCP -preventative care instructions -follow up with specialist -lifestyle recommendations

What surgical procedure should be performed to diagnose CAD?

Angioplasty

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 include herniated discs. Which organ system should this PE findings 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 perspectives) is where you document the story of the chief complaint and what brought the patient to see the doctor."

History of present illness