scribeamerica Outpatient Final exam
2023
What does "PHI" stand for? Expand the abbreviation - ANSWER-
protected health information
What medical term describes the surgical removal of the gallbladder? -
ANSWER- cholecystectomy
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
A patient's PCP is on vacation. The patient is scheduling to see the NP who is
covering for the PCP during this time. The patient has never been seen by
the NP before. Is the patient considered a new patient or an established
patient? - ANSWER-Established
What is the medical abbreviation for the condition commonly described
as "reflux" - ANSWER-GERD
What medical term would best describe "the likely course or outcome of a
disease?" - ANSWER-prognosis
Which section of the chart should you document when you hear the
following cue "what medical problems do you have?" - ANSWER-PHx
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? - ANSWER- multiple complaints 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? - ANSWER-chronological structure
Which of the following would be valid complications for CAD? (Select all
that apply) - ANSWER-MI
11. What are the possible consequences of a HIPAA violation? (Select all
that apply) - ANSWER-*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
, What does HIPAA stand for? Expand the abbreviation. - ANSWER-Health
Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose
level or HbA1c? Two words, expand the abbreviation. - ANSWER-diabetes
mellitus
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
15. Which of the following would be documented in the Objective section of
the SOAP note? (select all that apply) - ANSWER-*Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to . (select the best option) -
ANSWER- maintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood
clot in the lungs"? (Use the abbreviation form of the condition) -
ANSWER-PE
What chronic condition would require diagnosis through a lipid panel?
Use the abbreviation form. - ANSWER-HLD
Which of the following are considered non-reimbursable chief complaints?
(Select all that apply) - ANSWER-*follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork
and does not know what medications he should be taking at home. He asks
you to look up his medical record when you go to your shift today, giving
you verbal permission to access his information. In this scenario, it is
justifiable for you to use your EMR login to look up the important patient
information. - ANSWER-False
A patient is s/p angioplasty with stent and quadruple cardiac bypass.
What chronic condition should be included in their diagnosis today?
Expand the abbreviation? - ANSWER-coronary artery disease
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?
- ANSWER-Waxing and waning
2023
What does "PHI" stand for? Expand the abbreviation - ANSWER-
protected health information
What medical term describes the surgical removal of the gallbladder? -
ANSWER- cholecystectomy
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
A patient's PCP is on vacation. The patient is scheduling to see the NP who is
covering for the PCP during this time. The patient has never been seen by
the NP before. Is the patient considered a new patient or an established
patient? - ANSWER-Established
What is the medical abbreviation for the condition commonly described
as "reflux" - ANSWER-GERD
What medical term would best describe "the likely course or outcome of a
disease?" - ANSWER-prognosis
Which section of the chart should you document when you hear the
following cue "what medical problems do you have?" - ANSWER-PHx
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? - ANSWER- multiple complaints 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? - ANSWER-chronological structure
Which of the following would be valid complications for CAD? (Select all
that apply) - ANSWER-MI
11. What are the possible consequences of a HIPAA violation? (Select all
that apply) - ANSWER-*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
, What does HIPAA stand for? Expand the abbreviation. - ANSWER-Health
Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose
level or HbA1c? Two words, expand the abbreviation. - ANSWER-diabetes
mellitus
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
15. Which of the following would be documented in the Objective section of
the SOAP note? (select all that apply) - ANSWER-*Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to . (select the best option) -
ANSWER- maintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood
clot in the lungs"? (Use the abbreviation form of the condition) -
ANSWER-PE
What chronic condition would require diagnosis through a lipid panel?
Use the abbreviation form. - ANSWER-HLD
Which of the following are considered non-reimbursable chief complaints?
(Select all that apply) - ANSWER-*follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork
and does not know what medications he should be taking at home. He asks
you to look up his medical record when you go to your shift today, giving
you verbal permission to access his information. In this scenario, it is
justifiable for you to use your EMR login to look up the important patient
information. - ANSWER-False
A patient is s/p angioplasty with stent and quadruple cardiac bypass.
What chronic condition should be included in their diagnosis today?
Expand the abbreviation? - ANSWER-coronary artery disease
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?
- ANSWER-Waxing and waning
