Scribe U Final Questions and Answers Already Passed

What does CP stand for? - ANSWER-Chest Pain What does PHI stand for? - ANSWER-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. - ANSWER-False What is NOT the purpose of HITECH? - ANSWER-- To required patient accountability in paying for their health care visit - To require government accountability on health insurance plans available in the marketplace - To require equal access, opportunity, and affordability for health insurance plans by screening patient health information What are the possible consequences of a HIPAA violation? - ANSWER-- Termination - Monetary fines to you and the hospital - Prison time - Lawsuit against you and the hospital - Violator is blacklisted from medical programs - Scribe program cancellation What does HIPAA stand for? - ANSWER-Health Insurance Portability and Accountability Act HIPAA is a set of laws designed to - ANSWER-maintain patient privacy and confidentiality If a patient signs a waiver giving you permission to capture a photo of their unique rash, would you be committing a HIPPA violation by using your cellphone to capture the photo? - ANSWER-Yes because the phone is not an approved hospital device and it is not encrypted T/F: One of your coworkers 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. - ANSWER-False What are scribes NOT allowed to do? - ANSWER-- Touch patients - Perform clinical tasks (e.g. taking vitals) - Sign off on orders or prescriptions - Transport patient specimens to the laboratory - Give verbal orders - Give CPR 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? - ANSWER-Yes, because the fever started soon after the cough A patient states that he has been having abdominal pain for the last three days, and it varies between mild and severe. What would best describe the Timing? - ANSWERWaxing and waning T/F. All symptoms documented in the ROS are also documented in the HPI. - ANSWER-False A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you would type 0,0,0 with no spaces before or after the answer) - ANSWER-5,2,2 What is considered to be cardiac risk factors for CP patients? - ANSWER-HTN, HLD, family Hx of CAD 55 y/o, PSHx of CABG/angioplasty/stent, DM, CAD, tobacco use What FHx/SHx information is usually asked for pediatric patients? - ANSWER-Second hand smoke exposure Immunization status What medical term describes the surgical removal of the gallbladder? - ANSWERcholecystectomy Which section of the chart should you document when you hear the following cue "what medical problems do you have"? - ANSWER-PHx What is the medical term for "open heart surgery"? - ANSWER-Coronary Artery Bypass Graft What ROS system would include dysphagia, the medical term for difficult or painful swallowing? - ANSWER-ENT What is the medical term for "slow heart rate"? - ANSWER-Bradycardia What is the medical term for "pass out"? - ANSWER-syncope You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "The pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam? (Neck, top of foot, wrist, back of foot → 2+ radial pulse, 2+ PT pulse, 2+ DP pulse, 2+ carotid pulse) - ANSWER-- Neck: 2+ carotid pulse - Top of foot: 2+ DP pulse - Wrist: 2+ radial pulse - Back of foot: 2+ PT pulse A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - ANSWER-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? - ANSWER-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? - ANSWER-yes What medical term would best describe "the likely course or outcome of a disease"? - ANSWER-prognosis 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? - ANSWERMultiple Complaints Structure What medical term would describe a patient with a history of infection or inflammation of the liver? For correct billing and reimbursement to go through, a counseling note requires documentation of the following: - ANSWER-hepatitis For correct billing and reimbursement to go through a counseling note requires documentation of what? - ANSWER-- 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 admissions for lung cancer. Which HPI structure would be the best to use in this scenario? - ANSWER-chronological structure What would be a valid complication for CAD? - ANSWER-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