final exam- scribe
What medical term describes the surgical removal of the gallbladder? - Answers -
Cholecystectomy
What does "PHI" stand for? - Answers -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. - Answers -False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - Answers -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? - Answers -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? - Answers -Yes
What medical term would best describe "the likely course or outcome of a disease"? -
Answers -Prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have"? - Answers -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? - Answers -
Multiple complaints structure
Which of the following is NOT a purpose of HITECH? - Answers -1. To require equal
access, opportunity, and affordability for health insurance plans by screening patient
health information
2. To require government accountability on health insurance plans available in the
market place
3. To require encryption when using technology to transmit patient related information
4. To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or inflammation of
the liver? - Answers -Hepatitis
, For correct billing and reimbursement to go through, a counseling note requires
docuementation of the following: - Answers -1. Total time with the patient
2. 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? - Answers -Chronologic Structure and Multiple complaints structure
Which of the following would be valid complications for CAD? - Answers -MI
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. -
Answers -Yes, it is level 4.
What are the possible consequences of a HIPAA violation? - Answers -1. Scribe
program cancellation
2. Prison time
3. Termination
4. Violator is blacklisted from medical programs like Medical, PA, or NP school
5. Monetary fines to you and the hospital
6. Lawsuit against you and the hospital
What does HIPAA stand for? - Answers -Health Insurance Portability and Accountability
Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? - Answers -Diabetes
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? - Answers -Yes, because the fever started soon
after the cough
Which of the following would be documented in the Objective section of the SOAP
note? - Answers -1. Orders
2. Physical Exam
3. Treatments
4. Interpretations/results
HIPAA is a set of laws designed to _______. - Answers -maintain patient privacy and
confidentiality
What medical term describes the surgical removal of the gallbladder? - Answers -
Cholecystectomy
What does "PHI" stand for? - Answers -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. - Answers -False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - Answers -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? - Answers -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? - Answers -Yes
What medical term would best describe "the likely course or outcome of a disease"? -
Answers -Prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have"? - Answers -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? - Answers -
Multiple complaints structure
Which of the following is NOT a purpose of HITECH? - Answers -1. To require equal
access, opportunity, and affordability for health insurance plans by screening patient
health information
2. To require government accountability on health insurance plans available in the
market place
3. To require encryption when using technology to transmit patient related information
4. To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or inflammation of
the liver? - Answers -Hepatitis
, For correct billing and reimbursement to go through, a counseling note requires
docuementation of the following: - Answers -1. Total time with the patient
2. 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? - Answers -Chronologic Structure and Multiple complaints structure
Which of the following would be valid complications for CAD? - Answers -MI
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. -
Answers -Yes, it is level 4.
What are the possible consequences of a HIPAA violation? - Answers -1. Scribe
program cancellation
2. Prison time
3. Termination
4. Violator is blacklisted from medical programs like Medical, PA, or NP school
5. Monetary fines to you and the hospital
6. Lawsuit against you and the hospital
What does HIPAA stand for? - Answers -Health Insurance Portability and Accountability
Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? - Answers -Diabetes
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? - Answers -Yes, because the fever started soon
after the cough
Which of the following would be documented in the Objective section of the SOAP
note? - Answers -1. Orders
2. Physical Exam
3. Treatments
4. Interpretations/results
HIPAA is a set of laws designed to _______. - Answers -maintain patient privacy and
confidentiality
