ScribeAmerica OP Final With 103 Ques ons and
answers Newest RATED A+ 2025/2026 NEW!!
GUARANTEED SUCCESS
* What medical term describes the surgical removal of the gallbladder? - Ans cholecystectomy
What does "PHI" stand for? Expand the abbrevia!on. - Ans Protected Health Informa!on
T/F. Sharing informa!on about a case with family is allowed, as long as you are scribing with the
physician assigned to the case. - Ans False
** A pa!ent underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record into the chart? - Ans craniotomy
A pa!ent's PCP is on vaca!on. The pa!ent is scheduled to see the NP who is covering for the
PCP during this !me. The pa!ent has never been seen by the NP before. Is this pa!ent
considered a new pa!ent or an established pa!ent? - Ans Established
A pa!ent is diagnosed with back strain caused by heavy li-ing. As part of the treatment, the
physician discusses 4-5 different back stretching exercises that the pa!ent can perform every
morning and before doing any heavy li-ing. The discussion only takes 10 minutes of a 15 minute
Established Pa!ent visit. Would your physician be able to bill counseling !me on this pa!ent? -
Ans Yes
What medical term would best describe "the likely course or outcome of a disease"? - Ans
Prognosis
, Which sec!on of the chart should you document when you hear the following cue "what
medical problems do you have"? - Ans PHx
You are wri!ng an HPI for a pa!ent who presented for hyperlipidemia management. In the
middle of the visit, your pa!ent also reports having recently experienced urinary symptoms.
Which HPI structure would be the best to use in this scenario? - Ans Mul!ple complaints
structure
Which of the following is NOT a purpose of HITECH? - Ans - To require pa!ent 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
pa!ent health informa!on
What medical term would describe a pa!ent with a history of infec!on or inflamma!on of the
liver? - Ans Hepa!!s
For correct billing and reimbursement to go through, a counseling note requires documenta!on
of the following: - Ans - Total !me with the pa!ent
- Percentage of !me spent counseling
You are wri!ng an HPI for a very complex pa!ent who has had mul!ple recent hospital
admissions for lung cancer. Which HPI structure would be the best to use in this scenario? - Ans
Chronologic structure
Which of the following would be valid complica!ons for CAD? - Ans MI
* 57 year old male pa!ent presented with RLQ abdominal pain, which began 5 days ago. He
states that he was mowing the lawn when the pain began. Pa!ent reports he took OTC Tylenol
answers Newest RATED A+ 2025/2026 NEW!!
GUARANTEED SUCCESS
* What medical term describes the surgical removal of the gallbladder? - Ans cholecystectomy
What does "PHI" stand for? Expand the abbrevia!on. - Ans Protected Health Informa!on
T/F. Sharing informa!on about a case with family is allowed, as long as you are scribing with the
physician assigned to the case. - Ans False
** A pa!ent underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record into the chart? - Ans craniotomy
A pa!ent's PCP is on vaca!on. The pa!ent is scheduled to see the NP who is covering for the
PCP during this !me. The pa!ent has never been seen by the NP before. Is this pa!ent
considered a new pa!ent or an established pa!ent? - Ans Established
A pa!ent is diagnosed with back strain caused by heavy li-ing. As part of the treatment, the
physician discusses 4-5 different back stretching exercises that the pa!ent can perform every
morning and before doing any heavy li-ing. The discussion only takes 10 minutes of a 15 minute
Established Pa!ent visit. Would your physician be able to bill counseling !me on this pa!ent? -
Ans Yes
What medical term would best describe "the likely course or outcome of a disease"? - Ans
Prognosis
, Which sec!on of the chart should you document when you hear the following cue "what
medical problems do you have"? - Ans PHx
You are wri!ng an HPI for a pa!ent who presented for hyperlipidemia management. In the
middle of the visit, your pa!ent also reports having recently experienced urinary symptoms.
Which HPI structure would be the best to use in this scenario? - Ans Mul!ple complaints
structure
Which of the following is NOT a purpose of HITECH? - Ans - To require pa!ent 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
pa!ent health informa!on
What medical term would describe a pa!ent with a history of infec!on or inflamma!on of the
liver? - Ans Hepa!!s
For correct billing and reimbursement to go through, a counseling note requires documenta!on
of the following: - Ans - Total !me with the pa!ent
- Percentage of !me spent counseling
You are wri!ng an HPI for a very complex pa!ent who has had mul!ple recent hospital
admissions for lung cancer. Which HPI structure would be the best to use in this scenario? - Ans
Chronologic structure
Which of the following would be valid complica!ons for CAD? - Ans MI
* 57 year old male pa!ent presented with RLQ abdominal pain, which began 5 days ago. He
states that he was mowing the lawn when the pain began. Pa!ent reports he took OTC Tylenol
