Scribe America OP Final Exam with 100% Correct Answers 2023/2024

ScribeAmerica OP Final Exam What medical term describes the surgical removal of the gallbladder? - Correct answer- cholecystectomy What does "PHI" stand for? Expand the abbreviation. - Correct 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. - Correct answer-False What medical term would best describe "the likely course or outcome of a disease"? - Correct answer-Prognosis ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Correct 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? - Correct 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? - Correct answer-Yes What medical term would describe a patient with a history of infection or inflammation of the liver? - Correct answer-Hepatitis For correct billing and reimbursement to go through, a counseling note requires documentation of the following: - Correct 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? - Correct answer-Chronologic structure Which of the following would be valid complications for CAD? - Correct answer-MI * 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, vomiting or diarrhea. - Correct answer-Yes, the HPI meets Level 4 billing criteria. What are the possible consequences of a HIPAA violation? (select all that apply) - HIPAA is a set of laws designed to _______. (Select the best option.) - Correct answer- maintain patient privacy and confidentiality What condition correctly describes "blood clot in the lungs"? (Use the abbreviation form of the condition) - Correct answer-PE * MACRA - Correct answer-government healthcare initiative that focuses on quality of care to improve patient outcomes. * MIPS - Correct answer-system of payment in which government funding is released if specific quality measures are tracked Quality Measures - Correct answer-site specific health criteria that are tracked High Risk - Correct answer- Moderate Risk - Correct answer- Low Risk - Correct answer- What chronic condition would require diagnosis through a lipid panel? Use the abbreviation form. - Correct answer-HLD CP - Correct answer-chest pain 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? - Correct answer-waxing and waning The patient reports a tenderness in their right upper abdomen that began 2 weeks ago. Based on that information, do you document RUQ tenderness under the physical exam? - Correct answer-No