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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.
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?
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?
Which of the following is NOT a purpose of HITECH?
To require equal access
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 docuementation of the following:
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 and Multiple complaints 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
What are the possible consequences of a HIPAA violation?
Scribe program cancellation
Prison time
Termination
Violator is blacklisted from medical programs like Medical
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or HbA1c?
Diabetes
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?
Which of the following would be documented in the Objective section of the SOAP note?
Orders
Physical Exam
Treatments
Interpretations/results
HIPAA is a set of laws designed to _______.
maintain patient privacy and confidentiality
What condition correctly describes "blood clot in the lungs"?
PE
MACRA
Medicare Access and CHIP Reauthorization Act-government health care initiative that focuses on quality of care to improve patient outcomes
MIPS
Merit-based Incentive Payment System- system of payment which government funding is released if specific quality measures are tracked
Quality Measures
site specific health criteria that are tracked
Patient with acute exacerbation of ESRD requiring emergency dialysis
High risk
Patient with stable HTN and no other comorbities
Low risk
Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment
Moderate risk
What chronic condition would require diagnosis through a lipid panel?
CVD cardiovascular disease
Which of the following are considered non-reimbursable chief complaints?
Lab results
Follow-up
Medication refill
Check-up
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
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-Benign Prostatic Hyperplasia
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?
Which of the following would be included in a Problem List?
Family hx of renal cancer Pyelonephritis
resolved Hx of renal stone extraction Nephrolithiasis
What condition correctly describes "heart attack"?
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?
Benign Prostate Hyperplasia-
What medical term is used to describe the symptom of a patient's heart beating rapidly
irregularly
"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."
What details does this include?
Diagnosis
Prognosis/Plan
Age and sex
PHx
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
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?
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 fractures. What PMHx would you record into the chart?
Bone Fx
Organize the parts of the chart in order from top (1) to bottom (7).
HPI
ROS
PMHx
PE
Orders/Results
Assessment
Plan
What ROS system would include dysphagia
the medical term for difficult or painful swallowing?
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?
CABG
A female patient has been pregnant four times in the past
is currently pregnant
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.
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 are considered to be cardiac risk factors for CP patients? (cerebral Palsey)
Family hx of CAD <55 y/o HLD CAD PSHx of CABG
What is the medical term for "slow heart rate"?
Bradycardia
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 a track of patients that meet criteria for quality measures.
Prompt the provider to perform a quality measure.
"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?
Onset date
Resolved date
Note
What condition correctly describes "A blood clot in the extremities"?
DVT- deep vein thrombosis
A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart?
Mastectomy
HCC code
Codes for risk
E&M code
codes for reimbursement
ICD code
codes for diagnosis
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?
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.
True
A 45 year old male presents to the clinic with a constant
ripping
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?
LOS 5
Match the chronic condition with it's corresponding nonpharmacological treatment:
DM
Low carb diet
Match the chronic condition with it's corresponding nonpharmacological treatment:
HTN
Low sodium diet
Match the chronic condition with it's corresponding nonpharmacological treatment:
HLD
Low fat diet
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?
Salpingectomy
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 test
Reason for why the test was ordered
Result of test
Which of the following details could be categorized as the HPI element context?
Information regarding prior episodes
Which symptom(s) would a patient most likely present with if they had asthma?
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?
E&M code
Which of the following would be valid complications for HTN?
CRF
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 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?
Dyspnea
What ROS system would include menorrhagia
the medical term for "abnormally heavy or prolonged vaginal bleeding"?
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
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.
Back: CVA tenderness. Abdomen: no abdominal tenderness.
Eyes: PERRL
pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact. 3. Extremities: Non-tender. Skin: burning rash. Constitutional: No fever or chills. ENT: Copious rhinorrhea.
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 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
Note
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