Scribe America OP Final Exam 2024
Questions and Answers (Verified Answers)
* What medical term describes the surgical removal of the gallbladder?
cholecystectomy
What does "PHI" stand for? Expand the abbreviation.
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.
False
** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would
you record into the chart?
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?
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?
Yes
What medical term would best describe "the likely course or outcome of a disease"?
Prognosis
Which section of the chart should you document when you hear the following cue "what medical
problems do you have"?
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?
Multiple complaints structure
Which of the following is NOT a purpose of HITECH?
- To require patient accountability in paying for their health care visit
- To require government accountability on health insurance plans available in the market place
-To require equal access, opportunity, and affordability for health insurance plans by screening
patient health information
What medical term would describe a patient with a history of infection or inflammation of the liver?
, Hepatitis
For correct billing and reimbursement to go through, a counseling note requires documentation of
the following:
- 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?
Chronologic structure
Which of the following would be valid complications for CAD?
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.
Yes, the HPI meets Level 4 billing criteria.
What are the possible consequences of a HIPAA violation? (select all that apply)
- 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. Remember, do not include any spaces before
or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".
Health Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT:
two words. Expand abbreviations.
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?
Yes, because the fever started soon after the cough
* Which of the following would be documented in the Objective section of the SOAP note? (select all
that apply.)
- Orders
- Interpretations/results
- Treatments (that may involve medication or procedures)
- Physical exam
HIPAA is a set of laws designed to _______. (Select the best option.)
Questions and Answers (Verified Answers)
* What medical term describes the surgical removal of the gallbladder?
cholecystectomy
What does "PHI" stand for? Expand the abbreviation.
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.
False
** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would
you record into the chart?
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?
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?
Yes
What medical term would best describe "the likely course or outcome of a disease"?
Prognosis
Which section of the chart should you document when you hear the following cue "what medical
problems do you have"?
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?
Multiple complaints structure
Which of the following is NOT a purpose of HITECH?
- To require patient accountability in paying for their health care visit
- To require government accountability on health insurance plans available in the market place
-To require equal access, opportunity, and affordability for health insurance plans by screening
patient health information
What medical term would describe a patient with a history of infection or inflammation of the liver?
, Hepatitis
For correct billing and reimbursement to go through, a counseling note requires documentation of
the following:
- 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?
Chronologic structure
Which of the following would be valid complications for CAD?
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.
Yes, the HPI meets Level 4 billing criteria.
What are the possible consequences of a HIPAA violation? (select all that apply)
- 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. Remember, do not include any spaces before
or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".
Health Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT:
two words. Expand abbreviations.
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?
Yes, because the fever started soon after the cough
* Which of the following would be documented in the Objective section of the SOAP note? (select all
that apply.)
- Orders
- Interpretations/results
- Treatments (that may involve medication or procedures)
- Physical exam
HIPAA is a set of laws designed to _______. (Select the best option.)
