ScribeAmerica - FINAL EXAM - GENERAL OP Score 80 -
90% to pass GUARANTEED SUCCESS 2025/2026 NEW
EDITION
Cholecystectomy
What medical term describes the surgical removal of the gallbladder?
Protected Health Information
What does PHI stand for? Expand the abbreviation.
False
T/F Sharing information about a case with family is allowed, as long as you are scribing with the
physician assigned to the case.
Craniotomy
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record in the chart?
Established
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 establish patient?
Yes
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?
Prognosis
What medical term would best describe " the likely course or outcome of a disease?"
PHx
What section of the chart should you document when you hear the following cue "what medical
problems do you have?"
, Multiple Complaints Structure
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?
+ require patient accountability in paying for their health care visit (select)
⬛ require patient privacy and confidentiality
✓
+ require government accountability on health insurance plans available in the market place
(select)
+ require equal access, opportunity, and affordability for health insurance plans by screening
patient health information (select)
✓ require encryption when using technology to transmit patient related information
⬛
Which of the following is NOT A PURPOSE OF HITECH select all that apply
Hepatitis
What medical term would describe a patient with a history of infection or inflammation of the
liver?
Total time with the patient
Percentage of time spent counseling
For correct billing and reimbursement to go through, a counseling note requires documentation
of the following
Chronologic Structure
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?
MI
Which of the following would be valid complications for CAD?
Yes, the HPI meets Level 4 billing criteria.
90% to pass GUARANTEED SUCCESS 2025/2026 NEW
EDITION
Cholecystectomy
What medical term describes the surgical removal of the gallbladder?
Protected Health Information
What does PHI stand for? Expand the abbreviation.
False
T/F Sharing information about a case with family is allowed, as long as you are scribing with the
physician assigned to the case.
Craniotomy
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record in the chart?
Established
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 establish patient?
Yes
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?
Prognosis
What medical term would best describe " the likely course or outcome of a disease?"
PHx
What section of the chart should you document when you hear the following cue "what medical
problems do you have?"
, Multiple Complaints Structure
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?
+ require patient accountability in paying for their health care visit (select)
⬛ require patient privacy and confidentiality
✓
+ require government accountability on health insurance plans available in the market place
(select)
+ require equal access, opportunity, and affordability for health insurance plans by screening
patient health information (select)
✓ require encryption when using technology to transmit patient related information
⬛
Which of the following is NOT A PURPOSE OF HITECH select all that apply
Hepatitis
What medical term would describe a patient with a history of infection or inflammation of the
liver?
Total time with the patient
Percentage of time spent counseling
For correct billing and reimbursement to go through, a counseling note requires documentation
of the following
Chronologic Structure
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?
MI
Which of the following would be valid complications for CAD?
Yes, the HPI meets Level 4 billing criteria.
