ScribeAmerica OP Final Exam with 100%
Correct Answers 2023
pain vs tenderness - Correct answer-patient's feeling vs physician's assessment
acute vs chronic - Correct answer-new onset vs long standing
Meaningful Use (MU) - Correct answer-a set of government mandated criteria that must
be obtained for every patient
Medical decision making - Correct answer-the physician's thought process
Mid-level providers: - Correct answer-Nurse Practitioner (LNP) or Physician's Assistant
(PA) that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - Correct answer-records medical histories and symptoms,
monitors the patient, completes meaning use requirements, administers medications,
assists with procedures
Receptionist - Correct answer-answers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - Correct answer-documents the patient's visit on behalf of the physician
Scribes CANNOT... - Correct answer--partake in any activity that may affect patient
health or outcome
-touch patients
-handle bodily fluids or specimens
-sign or authenticate any chart or record
-give verbal orders or submit electronic orders
Scribes CAN... - Correct answer--document the history, physical exam, results,
procedures, assessment and plan
-access and document laboratory results and radiology findings
-locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
New patients - Correct answer--no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new
, Established patients - Correct answer--previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years
Diagnostic visit - Correct answer--new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary
Health Maintenance visit - Correct answer--check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems
allergy - Correct answer-a medication that causes a rash, itching, swelling, or difficulty
breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy
Hypertension (HTN) - Correct answer-high blood pressure
Hyperlipidemia (HLD) - Correct answer-high cholesterol
Normal heart rate - Correct answer-60-100 bpm
Pulmonary Embolism (PE) - Correct answer-blood clot in lung
Gravida/Para/Abortion - Correct answer-G - the total number of times the patient has
been pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions
Cerebrovascular Accident (CVA) - Correct answer-stroke
Transient Ischemic Attack (TIA) - Correct answer-mini-stroke
Tonsillectomy - Correct answer-tonsils removed
Adenoidectomy - Correct answer-adenoids removed
Coronary Artery Bypass Graft - Correct answer-heart bypass (PMHx CAD)
Angioplasty - Correct answer-balloon
Automatic Implanted Cardiac-Defribrillator (AICD) - Correct answer-defibrillator
Mastectomy - Correct answer-breast removal
Correct Answers 2023
pain vs tenderness - Correct answer-patient's feeling vs physician's assessment
acute vs chronic - Correct answer-new onset vs long standing
Meaningful Use (MU) - Correct answer-a set of government mandated criteria that must
be obtained for every patient
Medical decision making - Correct answer-the physician's thought process
Mid-level providers: - Correct answer-Nurse Practitioner (LNP) or Physician's Assistant
(PA) that works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - Correct answer-records medical histories and symptoms,
monitors the patient, completes meaning use requirements, administers medications,
assists with procedures
Receptionist - Correct answer-answers phone calls, schedules appointments, answers
patient questions, provides patient with summary of visit and written instructions from
provider at check-out, and organizes the patient's paperwork
Scribe - Correct answer-documents the patient's visit on behalf of the physician
Scribes CANNOT... - Correct answer--partake in any activity that may affect patient
health or outcome
-touch patients
-handle bodily fluids or specimens
-sign or authenticate any chart or record
-give verbal orders or submit electronic orders
Scribes CAN... - Correct answer--document the history, physical exam, results,
procedures, assessment and plan
-access and document laboratory results and radiology findings
-locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
New patients - Correct answer--no previous records
-longer visit
-detailed chart
-if patient hasn't been seen in 3 years at the clinic, they are considered new
, Established patients - Correct answer--previous records available
-shorter visit
-concise chart
-must've been seen in the clinic in the last three years
Diagnostic visit - Correct answer--new problem
-CC: new symptom
-goal is to determine the cause of the problem and appropriate treatment
-differential diagnosis is necessary
Health Maintenance visit - Correct answer--check-up
-CC: management of chronic problem
-goal is to assess progress of ongoing/chronic medical problems
allergy - Correct answer-a medication that causes a rash, itching, swelling, or difficulty
breathing
-if these symptoms not seen, it is an "adverse reaction", not an allergy
Hypertension (HTN) - Correct answer-high blood pressure
Hyperlipidemia (HLD) - Correct answer-high cholesterol
Normal heart rate - Correct answer-60-100 bpm
Pulmonary Embolism (PE) - Correct answer-blood clot in lung
Gravida/Para/Abortion - Correct answer-G - the total number of times the patient has
been pregnant
P - the # of live births the pt has had
A - the # of miscarriages or elective abortions
Cerebrovascular Accident (CVA) - Correct answer-stroke
Transient Ischemic Attack (TIA) - Correct answer-mini-stroke
Tonsillectomy - Correct answer-tonsils removed
Adenoidectomy - Correct answer-adenoids removed
Coronary Artery Bypass Graft - Correct answer-heart bypass (PMHx CAD)
Angioplasty - Correct answer-balloon
Automatic Implanted Cardiac-Defribrillator (AICD) - Correct answer-defibrillator
Mastectomy - Correct answer-breast removal
