Scribe America Final Exam Study Guide
Questions And Answers Verified 100%
Correct
Why is documenting a thorough HPI important? - ANSWER- The HPI
serves as the basis for the workup that follows.
Name the 8 elements of the HPI. - ANSWER- Onset
Timing
Location
Quality
Severity
Modifying Factors
Associated Sx
Context
Name two items that are important to include in the HPI of a patient who
has had similar symptoms in the past. - ANSWER- Anything new or
different about their symptoms today?
How long ago did the similar symptoms occur? Did the patient seek
professional treatment at the time?
Was there any result or diagnosis from previous evaluation.
What are four important details to include in the HPI of a patient who
has been evaluated by another healthcare provider for similar
symptoms? - ANSWER- - Who ordered the test
- Name/Result/Date of test
- Final Dx given
Explain a method of "checking" your chart for completeness. -
,ANSWER- HPI should be mentioned in ROS, PE, Assessment, Orders
Is the chief complaint one of the eight ELEMENTS of the HPI? -
ANSWER- NO.
Which HPI structure is best to use for a complex patient with multiple
co-morbidities and a recent work-up? - ANSWER- Multiple Complaint
Formula
The multiple complaint formula is used primarily in which specialty? -
ANSWER- Primary care or Internal Medicine OP practice.
T/F : The first step in every HPI structure begins with the age and sex of
the patient. - ANSWER- True
Which HPI structure is best for a patient with a single complaint? -
ANSWER- Single Complaint Formula
T/F : Abbreviations are permitted in the HPI as long as they are
approved medical abbreviations. - ANSWER- True
T/F : It is okay for scribes to misspell words because doctors do it all the
time. - ANSWER- False
How would you document the onset of symptoms that began on
Wednesday? - ANSWER- Count the number of days since the symptoms
started.
If the patient says, "It hurts when I touch it," what would you write in the
HPI? - ANSWER- The symptoms are worsened by palpation of the area.
Give the definition of the word exacerbate. - ANSWER- To make worse.
, T/F : ROS stands for Review of Symptoms - ANSWER- False. Review
of Systems.
Can the ROS contradict information in the HPI? Why or why not? -
ANSWER-
T/F : The ROS does not contain the chief complaint and its associated
symptoms because they are already listed in the HPI. - ANSWER- True.
Name three symptoms that would be listed under the neurological
section of the ROS. - ANSWER- Headache, syncope, seizure,
numbness, focal weakness.
Why must you be ready to type or click quickly during a physician-led
ROS? - ANSWER- The physician will review all body-systems with the
patient while the scribe documents real-time.
T/F : "I don't have any responsibility with regards to the ROS because
the nurses complete the ROS at my facility." - ANSWER- True.
How will you document the ROS in most EMRs
Full sentences
Plus/minus checkboxes
Paragraphs - ANSWER- Plus/minus checkboxes.
What are three items that are included in the objective evaluation? -
ANSWER- Vital signs, physical exam, orders/results
T/F : The objective evaluation should be documented immediately after
the plan - ANSWER- False
Questions And Answers Verified 100%
Correct
Why is documenting a thorough HPI important? - ANSWER- The HPI
serves as the basis for the workup that follows.
Name the 8 elements of the HPI. - ANSWER- Onset
Timing
Location
Quality
Severity
Modifying Factors
Associated Sx
Context
Name two items that are important to include in the HPI of a patient who
has had similar symptoms in the past. - ANSWER- Anything new or
different about their symptoms today?
How long ago did the similar symptoms occur? Did the patient seek
professional treatment at the time?
Was there any result or diagnosis from previous evaluation.
What are four important details to include in the HPI of a patient who
has been evaluated by another healthcare provider for similar
symptoms? - ANSWER- - Who ordered the test
- Name/Result/Date of test
- Final Dx given
Explain a method of "checking" your chart for completeness. -
,ANSWER- HPI should be mentioned in ROS, PE, Assessment, Orders
Is the chief complaint one of the eight ELEMENTS of the HPI? -
ANSWER- NO.
Which HPI structure is best to use for a complex patient with multiple
co-morbidities and a recent work-up? - ANSWER- Multiple Complaint
Formula
The multiple complaint formula is used primarily in which specialty? -
ANSWER- Primary care or Internal Medicine OP practice.
T/F : The first step in every HPI structure begins with the age and sex of
the patient. - ANSWER- True
Which HPI structure is best for a patient with a single complaint? -
ANSWER- Single Complaint Formula
T/F : Abbreviations are permitted in the HPI as long as they are
approved medical abbreviations. - ANSWER- True
T/F : It is okay for scribes to misspell words because doctors do it all the
time. - ANSWER- False
How would you document the onset of symptoms that began on
Wednesday? - ANSWER- Count the number of days since the symptoms
started.
If the patient says, "It hurts when I touch it," what would you write in the
HPI? - ANSWER- The symptoms are worsened by palpation of the area.
Give the definition of the word exacerbate. - ANSWER- To make worse.
, T/F : ROS stands for Review of Symptoms - ANSWER- False. Review
of Systems.
Can the ROS contradict information in the HPI? Why or why not? -
ANSWER-
T/F : The ROS does not contain the chief complaint and its associated
symptoms because they are already listed in the HPI. - ANSWER- True.
Name three symptoms that would be listed under the neurological
section of the ROS. - ANSWER- Headache, syncope, seizure,
numbness, focal weakness.
Why must you be ready to type or click quickly during a physician-led
ROS? - ANSWER- The physician will review all body-systems with the
patient while the scribe documents real-time.
T/F : "I don't have any responsibility with regards to the ROS because
the nurses complete the ROS at my facility." - ANSWER- True.
How will you document the ROS in most EMRs
Full sentences
Plus/minus checkboxes
Paragraphs - ANSWER- Plus/minus checkboxes.
What are three items that are included in the objective evaluation? -
ANSWER- Vital signs, physical exam, orders/results
T/F : The objective evaluation should be documented immediately after
the plan - ANSWER- False
