SCRIBE AMERICA FINAL EXAM RETAKE ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES|AGRADE
Expand PHI - ANSWER: protected health information
What is the purpose of HITECH? - ANSWER: -To require patient privacy and
confidentiality
-To require encryption when using technology to transmit patient related
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 like Medical, PA, or NP school
Scribe program cancellation
(All of them)
HIPAA is a set of laws designed to _______. - ANSWER: maintain patient privacy and
confidentiality
Expand HIPAA - ANSWER: Health Insurance Portability and Accountability Act
Which of the following are considered to be cardiac risk factors for CP patients? -
ANSWER: HTN
HLD
Family hx of CAD <55 y/o
PSHx of CABG, angioplasty, and stent
DM
CAD
tobacco use
(All of them)
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
All symptoms documented in the ROS are also documented in the HPI. - ANSWER:
False
Surgical removal of the gallbladder - ANSWER: cholecystectomy
What is the medical term for "open heart surgery"? - ANSWER: coronary artery
bypass graft
What is the medical term for "pass-out"? - ANSWER: syncope
, What ROS system would include dysphagia, the medical term for difficult or painful
swallowing? - ANSWER: ENT
Which of the following would be documented in the Objective section of the SOAP
note? - ANSWER: -Orders
-Interpretations/results
-Treatments (that may involve medication or procedures)
-Physical exam
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 mowing the lawn when the pain began. Patient reports he
took OTC Tylenol yesterday without relief. There has been no nausea, vomiting or
diarrhea. - ANSWER: Yes, the HPI meets Level 4 billing criteria.
What condition correctly describes "blood clot in the lungs"? - ANSWER: Pulmonary
Embolism (pe)
What condition correctly describes "dangerous infection of the appendix"? -
ANSWER: appendicitis
What condition correctly describes "heart attack"? - ANSWER: Myocardial Infarction
(MI)
What condition correctly describes "Narrowing of the coronary arteries limits blood
supply to the heart muscle causing ischemia"? - ANSWER: coronary artery disease
(CAD)
What condition correctly describes "mini-stroke"? (Use the abbreviation form of the
condition. - ANSWER: transient ischemic attack (tia)
What condition correctly describes "A blood clot in the extremities"? - ANSWER:
deep vein thrombosis (dvt)
What medical term would describe a patient with a history of infection or
inflammation of the liver? - ANSWER: hepatitis
An elderly male patient has a history of an enlarged prostate. What PMHx would you
record into the chart? - ANSWER: Benign Prostate Hypertrophy (bph)
An elderly male patient has a history of an enlarged prostate and has undergone
surgery to treat his condition. What PSHx would you record into the chart? -
ANSWER: Prostatectomy (turp)
CORRECT DETAILED ANSWERS WITH RATIONALES|AGRADE
Expand PHI - ANSWER: protected health information
What is the purpose of HITECH? - ANSWER: -To require patient privacy and
confidentiality
-To require encryption when using technology to transmit patient related
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 like Medical, PA, or NP school
Scribe program cancellation
(All of them)
HIPAA is a set of laws designed to _______. - ANSWER: maintain patient privacy and
confidentiality
Expand HIPAA - ANSWER: Health Insurance Portability and Accountability Act
Which of the following are considered to be cardiac risk factors for CP patients? -
ANSWER: HTN
HLD
Family hx of CAD <55 y/o
PSHx of CABG, angioplasty, and stent
DM
CAD
tobacco use
(All of them)
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
All symptoms documented in the ROS are also documented in the HPI. - ANSWER:
False
Surgical removal of the gallbladder - ANSWER: cholecystectomy
What is the medical term for "open heart surgery"? - ANSWER: coronary artery
bypass graft
What is the medical term for "pass-out"? - ANSWER: syncope
, What ROS system would include dysphagia, the medical term for difficult or painful
swallowing? - ANSWER: ENT
Which of the following would be documented in the Objective section of the SOAP
note? - ANSWER: -Orders
-Interpretations/results
-Treatments (that may involve medication or procedures)
-Physical exam
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 mowing the lawn when the pain began. Patient reports he
took OTC Tylenol yesterday without relief. There has been no nausea, vomiting or
diarrhea. - ANSWER: Yes, the HPI meets Level 4 billing criteria.
What condition correctly describes "blood clot in the lungs"? - ANSWER: Pulmonary
Embolism (pe)
What condition correctly describes "dangerous infection of the appendix"? -
ANSWER: appendicitis
What condition correctly describes "heart attack"? - ANSWER: Myocardial Infarction
(MI)
What condition correctly describes "Narrowing of the coronary arteries limits blood
supply to the heart muscle causing ischemia"? - ANSWER: coronary artery disease
(CAD)
What condition correctly describes "mini-stroke"? (Use the abbreviation form of the
condition. - ANSWER: transient ischemic attack (tia)
What condition correctly describes "A blood clot in the extremities"? - ANSWER:
deep vein thrombosis (dvt)
What medical term would describe a patient with a history of infection or
inflammation of the liver? - ANSWER: hepatitis
An elderly male patient has a history of an enlarged prostate. What PMHx would you
record into the chart? - ANSWER: Benign Prostate Hypertrophy (bph)
An elderly male patient has a history of an enlarged prostate and has undergone
surgery to treat his condition. What PSHx would you record into the chart? -
ANSWER: Prostatectomy (turp)
