SA- Final Retake

Surgical removal of the gallbladder

cholecystectomy

PHI

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

Brain surgery to treat bleeding in the brain from stroke

craniotomy

A patient's PCP is on vacation. The patient is schedule 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 any heavy lifting. The discussion only takes 10 minute of the 15 minute Established patient visit. Would your physician be able to bill counseling time on this patient?

Yes

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 HLD management i the middle of the visit your patient also reports having recently experiences urinary symptoms. Which structure would be the best to use in the scenario.

Multiple Complaints structure

Which of the following is NOT a purpose of HITECH?

To require patient accountability in paying for their health care

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

Infection of 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 admission for lung cancer. Which HPI structure would be the best to use in this scenario?

Chronologic structure

Which of the following would be a valid complication of CAD?

MI

Does this HPI verify whether the 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 N/V/D.

Yes

What are the possible consequences of a HPIAA violation?

Select everything there

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

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 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?

Yes, the fever started soon after the cough

Which of the following would be documented in the Objective section of the SOAP note?

Orders

Interpretations/results

treatments that may involve medication nor procedures

physical exam

HIPAA is a set of laws designed to _______

maintain patient privacy and confidentiality

Blood clot in the lungs

PE (pulmonary embolism)

1. MACRA

2. MIPS

3. Quality measures

1. Government healthcare initiative that focus on quality of care to improve patient outcomes

2. System of payment in which government funding is released if specific quality measures are tracked

3. Site specific health criteria that are tracked

1. High risk

2. moderate risk

3. low risk

1. Patient with acute exacerbation of ESRD requiring emergency dialysis.

2. Asthmatic patient with acute exacerbation that is resolved in office with nebulizer treatment.

3. patient with Stable HTN and no other comorbities.

What chronic coniditon would require diagnosis through a lipid panel?

HLD (hyperlipidemia)

which of the following are considered non-reimbursable CC's?

Check - up

Follow - up

Lab results

Medication refill

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

Dangerous infection of the appendix

appendicitis

history of enlarge prostate

BPH (Bening prostate hypertrophy)

A patient is s/p angioplasty with stent and quadruple cardiac bypass . What chronic condition should be included i 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

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

No.

Heart attack

MI (myocardial infarction)

An elderly male patient has a Hx of an enlarged prostate and has undergone surgery to treat his condition. What PsHx do you record?

TURP

Heart beating rapidly irregularly or forcibly

Arrhythmia

Patient is a 56 y/o male with CRF first diagnoses 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN are 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 understand and agrees to be transferred to the ED.

Age and sex

PHx, if relevant

Dx

Results

(T/F) All systems documented in the ROS are also documented in the HPI

False

open heart surgery

Coronary Artery Bypass Graft (CABG)

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 that photo?

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

narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia

CAD

brittle bone disease

osteoporosis

physician examining patient by touch

palpation

organize the parts of the chart from top to bottom

HPI

ROS

PHx

PE

Orders/results

assessment

Plans

Dysphasia would be placed under which ROS system?

ENT

(T/F) The ROS does not contain the CC and its associated symptoms because it is already in the HPI

False

1. HEENT Throat

2. HEENT Ears

3. Cardiovascular

4. Pulmonary

5. Abdomen

6. Neurological

7. Skin

1. Pharyngeal erythema

2. TM erythema

3. Tachycardia

4. Rhonchi

5. Murphy's sign

6. Abscess with fluctuance

patient requires heart bypass

Coronary artery bypass graft (CABG)

Currently pregnant, has been pregnant four times with 2 kids

5,2,2

PERRL is documented under which body system for PE

Eyes

(T/F) It is acceptable to look up your own information

False

Mini-stroke

TIA (transient ischemic attack)

balloon to treat heart attack

angioplasty

cardiac risk factors for CP patients

HTN

HLD

Family hx of CAd

slow heart rate

bradycardia

having multiple chronic conditions

comorbidity

partial removal of the lung

Partial lobectomy

What can scribes 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.

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

Brief summary

wrist pulse

front of the foot pulse

neck pulse

back of the foot pulse

2+ radial pulse

2+ DP pulse

2+ caroti pulse

2+ PT pulse

blood clot in the extremities

DVT (deep vein thrombosis)

removal of breast surgery

mastectomy

ICD codes

E&M codes

HCC codes

dx

reimbursement

risk

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 the last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk of death and other complications if he does not seek further urgent medical attention. Patient understand and agrees to be transferred to the ED.

Comprehensive summary.

What Fhx/Shx is usually asked for pediatric patients?

Second hand smoke exposure

immunization status

Pass out

syncope

Symptoms a patient most likely present with if they had HLD

Asymptomatic

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 N that began 1 hour ago. He denies any accompanying dyspnea or diaphoresis. What elements are missing?

severity

modifying factors

relevant context

ovary removal

oophorectomy

A patient comes into the clinic for a well woman exam

Health management visit

A patient has an E&M code of 99215

Established

LOS 5

HTN

DM

HLD

Low sodium diet

low carb diet

low fat diet

what are scribe not allowed to do?

touch patients

perform clinical tasks

sign off on orders or rx

authenticate the chart

transport patient specimens to the lab

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

Ovary and fallopian tubes removed

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 reuslts in the assessment section?

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?

Info regarding prior episodes

info regarding prior evals

info regarding risk factors

symptoms if they had asthma

dyspnea

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

Diagnostic visit

which two codes should always be included in the superbill?

ICD codes and E&M code

Which of the following are valid complications of CAD?

CHF

MI

CRF

Impaired vision

CAD

A bacterial lung infection

PNA (pneumonia)

uterus removed

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.

False

Mid level provider

Nurse/MA

Secretary

Scribe

NP or PA

Records medical histories, symptoms, monitors the patientAnswers phone calls, pages

Documents the patient's visit

difficulty breathing

dyspnea

menorrhagia is under which ROS system?

genitourinary

Which of the following is included in the Plan section?

Prescription for medication

Prescription for diagnostic study

Follow up with PCP

Follow up with specialist

Lifestyle recommendations

Preventative care instructions

Diagnostic for CAD

Cardiac Catheterization

Do you document clear breath sounds bilaterally and rhonchi?

No, because they contradict eachother

Murphy's sign is examined in which organ system

abdomen

Which organ system for straight leg raise may indicate herniated disk?

Back

Identify which one has contradictory PE findings

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

When should the word lethargy be documented on the chart?

when the physician explicitly tells you to do so.

Why is it important to document patient tears?

Indicates that the patient is hydrated

bibasilar crackles is under which organ system in Assessment?

Respiratory

Subjective section which is the patient's story of why they are here

History of present illness.