SCRIBEAMERICA OUTPATIENT REVIEW EXAM ACTUAL
QUESTIONS AND ANSWERS SURE A+
✔✔* 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? (Select
all that apply - ✔✔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? - ✔✔- Severity
- Modifying factor
- Relevant context
✔✔A female patient underwent surgery to have her ovary removed. What PSHx would
you record into the chart? (Remember, do not include any spaces before or after the
term/phrase.) - ✔✔oopherectomy
✔✔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:
1) HTN
, 2) DM
3) HLD - ✔✔1) Low sodium diet, decrease EtOH intake, increase physical activity
2)low carb diet, increase phy. activity
3) low fat diet, incr. phy. activity
✔✔What are scribes NOT allowed to do? - ✔✔- Touch patients
- Perform clinical tasks (e.g. taking vitals)
- Sign off on orders or prescriptions
- Authenticate the chart
- Transport patient specimens to the laboratory
- 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. -
✔✔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
- Result 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 prior episodes
- Information regarding prior evaluations
- Information regarding risk factors (bp, medication compliance)
✔✔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 code
- E&M code
QUESTIONS AND ANSWERS SURE A+
✔✔* 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? (Select
all that apply - ✔✔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? - ✔✔- Severity
- Modifying factor
- Relevant context
✔✔A female patient underwent surgery to have her ovary removed. What PSHx would
you record into the chart? (Remember, do not include any spaces before or after the
term/phrase.) - ✔✔oopherectomy
✔✔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:
1) HTN
, 2) DM
3) HLD - ✔✔1) Low sodium diet, decrease EtOH intake, increase physical activity
2)low carb diet, increase phy. activity
3) low fat diet, incr. phy. activity
✔✔What are scribes NOT allowed to do? - ✔✔- Touch patients
- Perform clinical tasks (e.g. taking vitals)
- Sign off on orders or prescriptions
- Authenticate the chart
- Transport patient specimens to the laboratory
- 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. -
✔✔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
- Result 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 prior episodes
- Information regarding prior evaluations
- Information regarding risk factors (bp, medication compliance)
✔✔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 code
- E&M code
