Scribe University

Murphy's sign is examined in which organ system? -Abdomen -Neurologic -Respiratory -Cardiovascular

-Abdomen

Identify what details are included in the following Assessment. (Select all that apply.) "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED." -Age and sex -Phx in relevant -Diagnosis -Physical Exam -Results -Differential Diagnosis -HPI -Prognosis/Plan

-Age and sex -Phx if relevent -Diagnosis -Results -HPI -Prognosis/Plan

Which symptom(s) would a patient most likely present with if they had HLD? -Headache -Polyuria -Polydipsia -Dyspnea -Asymptomatic

-Asymptomatic

A positive straight-leg-raise may indicate herniated discs. Which organ system should this PE finding be documented in? -Cardiac -Lungs -Abd -Back -GU -Neuro -Psych

-Back

Determine which structure best firs the following Assessment. Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no visible signs of tonsils exudate. Rapid strep negative. -Simple statement -Brief summary -Comprehensive summary

-Brief summary

Which of the following would be valid complications for HTN? -CHF -MI -CRF -Impaired vision -Pancreatitis -CAD -Peripheral neuropathy

-CHF -MI -CRF -Impaired vision -CAD

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? -Single complaint structure -Multiple complaint structure -Chronologic Structure

-Chronologic structure

Determine which structure best fits the following Assessment. "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED." -Simple statement -Brief summary Comprehensive summary

-Comprehensive summary

A patient comes into the clinic for 3 weeks of a productive cough. What type of clinic visit is this? -Diagnostic visit -Health management visit

-Diagnostic visit

What can scribes in the clinic to help accomplish MACRA and MIPS goals?

-Document quality measures that are met by the physician during the visit -Prompt the provider to perform a quality measure -Use a tracking sheet to keep a track of patient that meet criteria for quality measures

Which symptom(s) would a patient most likely present with if they had asthma? -Headache -Polyuria -Polydipsia -Dyspnea

-Dyspnea

What ROS system wold include dysphasia, the medical term for difficult or painful swallowing? -General/constitutional -Eyes -ENT -Cardiac -Respiratory -Gastrointestinal -Genitourinary -Musculoskeletal -Neurological -Psychiatric

-ENT

A patient has an E&M code of 99215. What information does this code give? -New patient -Established patient -LOS 1 -LOS 2 -LOS 5 -LOS 9

-Established patient -LOS 5

What body system would the exam finding PEERL be documented in? -Skin -Musculoskeletal -Eyes -Respiratory -Gastrointestinal

-Eyes

Identify which of these selections contain contradictory physical exam findings. -Constitutional: No fever or chills. ENT: Copious rhinorrhea -Extremities: Non tender. Skin: burning rash -Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact. -Back: CVA tenderness. Abdomen: no abdominal tenderness

-Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: cranial nerves grossly intact

Which of the following are considered non-reimbursable chief complaints? -Annual visit -Follow-up -Check-up -Medication refill -Lab results

-Follow up -Check up -Medication refill -Lab results

What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"? -General/Constitutional -Eyes -ENT -Cardiac -Respiratory -Gastrointestinal -Musculoskeletal -Neurological -Psychiatric

-Genitourinary

Match the body system with the corresponding PE finding

-HEENT Throat=Pharyngeal erythema -HEENT Ears=TM erythema -Cardo= Tachycardia -Pulmonary=Rhonchi -Abdomen=Murphy's sign -Neurological=Alert and oriented x4 -Skin=Abscess with fluctuance

Which of the following are considered to be cardiac risk factors for CP patients? -HTN -HLD -Family history of Cad <55 y/o -PSHc of CABG, angioplasty, and stent -DM -CAD -tobacco use -none of the options listed

-HTN -HLD -Family hx of CAD <55 y/o PSHx of CABG, angioplasty, and stent -DM -CAD -tobacco use

Match the chronic condition with its corresponding non pharmacological treatment

-HTN: low sodium diet, decrease EtOH intake, increase physical activity -DM: low card diet, increase physical activity -HLD: low fat diet, increase physical activity

A patient comes into the clinic for a well woman exam. What type of clinic visit is this? -Diagnostic visit -Health Management visit

-Health management visit

Match the following scenario to the corresponding risk. High Risk, Moderate Risk, Low risk -Patient with stable HTN and no other comorbities -Asthmatic patient with acute acerbating that is resolve -Patient with acute execrations of ESRD requiring

-High risk= Patient with acute exertion of ESRD requiring -Moderate risk= asthmatic patient with acute acerbating that is resolve -Low risk= Patient with stable HTN and no other comorbities

Which two codes should always be included on every superbill? -ICD code -E&M code -HCC code -Counseling code -Procedure code -Modifier code

-ICD code -E&M code

Why might it be important to document the presence of tears for pediatric or adult patients? -Indicated that the patient is hydrated -It is not important to document the presence of tears -Indicates that the physician should be concerned -Indicated that the patient is upset.

-Indicated that the patient is hydrated

Which of the following details could be categorized as the HPI element context? -PHx information irrelevant to CC -Information regarding prior episodes -Information listing out pertinent positives and pertinent negatives -Information regarding prior evaluations -Information regarding risk factors

-Information regarding prior episodes -Information regarding prior evaluations -Information regarding risk factors

Matching the following description with the corresponding term MACRA, MIPS, Quality Measures -system of payment in which government funding is -site specific health criteria that are tracked -government healthcare initiative that focuses on quality

-MACRA= government healthcare initiative that focused on quality -MIPS= system of payment in which government funding is -Quality Measures= site specific health criteria that are tracked

Which of the following would be valid complications for CAD? -MI -Pancreatitis -Peripheral neuropathy

-MI

Match the description of the role with the team member.

-Mid Level Provider= Nurse Practitioner (NP) or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients. -Nurse/MA=Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures. -Secretary= Answers phone calls, pages other specialists/doctors, and organized the patient's paperwork -Scribe= Documents the patient's visit on behalf of the physician

What 3 details should be included in a sentence summarizing results in the Assessment Section? -Name of the rest -Result of the test -Reason for why was the test ordered -Name of the testing facility -Name of the interpreting physician

-Name of the test -Result of the test -Reason for why was the test ordered

Can you document both "clear breath sounds bilaterally" and "rhonchi in the right base"? Why or why not? -Yes, both of these are lung findings -No, both of these are breath sounds -No, because they contradict each other -yes, because they both indicate the patient is in no respiratory distress -yes, because one is an abnormality, and the other a normal findings

-No, because they contradict each other

When should the word "lethargy" be documented on the chart? -Usually for pediatric patients -Only for adult patients -Only when the physician explicitly tells you to do so -Never

-Only when the physician explicitly tells you to do so

Which of the following would be documented in the Objective section of the SOAP note? -Review of Symptoms -Orders -Family history -Interpretations/Results -Treatments (that may involve medication or procedures) -Physical exam -History of present illness -Disgnosis -Follow-up -Recommendations

-Orders -Interpretations/results -Treatments -Physical exam

Which of the following information should you be including in the plan section when documenting? -Prescription for medication -Prescription for diagnose study -Follow up with PCP -Follow up with specialist -Lifestyle recommendations -Preventative care instructions -Results -Diagnosis

-Prescriptions for medication -Prescription for diagnostic study -Follow up with PCP -Follow up with specialist -Lifestyle recommendations -Preventative care instructions

A modifier code usually gives information about which type of code? -ICD code -E&M coe -HCC code -Counseling code -Procedure code

-Procedure code

Your physician tells you the patient had bibasilar crackles on exam. In which organ system would you document this physical exam finding?

-Respiratory

Identify which these PE symptoms contains contradictory findings: -Constitutional: NAD. Afebrile -Abdomen: No abdominal tenderness. Diminished bowel sounds -Eyes: PERRL. Mild scleral icterus -Respiratory: No respiratory distress, tachypnea, lungs are clear to auscultation bilaterally.

-Respiratory: No respiratory distress, tachypnea, lungs are clear to auscultation bilaterally.

What FHx/SHx information is usually asked for pediatric patients? -Smoking history -Current occupation -Second hand smoke exposure -History of cardiac disease -Immunization status

-Second hand smoke exposure -Immunization status

What are the possible consequences of a HIPAA violation?

-Termination -Monetary fines to you and the hospital -Prison time -Lawsuit against you and the hospital -Violator is black listed from medical programs like Medical, PA, or NP school -Scribe program cancellation

Which of the following is NOT a purpose of HITECH? -To retire patients accountability in paying for their health care visit -To require patient privacy and confidentiality -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 -To require encryption when using technology to transmit patient related information

-To require patient accountability in paying for their health care visits -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

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 -Patient arrival time -Patient departure time -Total time spent counseling -Percentage of time spent with physician vs with nurse/MA

-Total time with the patient -Percentage of time spent counseling

What are scribes NOT allowed to do? -Touch patients -Perform clinical tasts -Document on patients charts -Sign off on orders or prescriptions -Authenticate the chart -Transport patient specimens to the laboratory -Give verbal orders -Give CPR -Access results and prior records

-Touch patients -Perform clinical tasks -Sign off on orders or prescriptions -Authenticate the chart -Transport patient specimens to the laboratory -Give verbal orders -Give CPR

If a patient signs a waiver giving you permission to capture photo of their unique rash would you be committing a HIPAA violation by using your cellphone to capture the photo? -Yes because the phone is not an approved hospital device -Yes because the phone is not encrypted -Yes because the phone is not an approved hospital device and it is not encrypted -No because the phone is not an approved hospital device -No because the phone is not encrypted -No because the phone is not an approved hospital device and that it is not encrypted

-Yes because the phone is not an approved hospital device and it is not encrypted

Verify if this HPI meets Level 4 billing criteria for a NEW patient: 57 yo 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, diarrhea.

-Yes, the HPI meets Level 4 billing criteria

HIPAA is a set of laws designed to _____ -maintain patient accountability in paying for their health care visit -maintain government accountability on health insurance plans available in the market place -maintain patient privacy and confidentiality -maintain equal access, opportunity, and affordability of health insurance plans

-maintain patient privacy and confidentiality

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? -single complaint structure -multiple complaints structure -chronologic structure

-multiple complaints structure

A 45 year old male presents to the clinic with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. He denies any accompanying dyspnea or diaphoresis. What elements are missing? (select all that apply.) -CC -Onset -Timing -Location -Quality -Severity -Pertinent positive/Pertinent negative -Modifying factor -relevant context

-severity -modifying factor -relevant context

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? -constant -intermittent -waxing and waning

-waxing and waning

Organize the parts of the chart in order from top to bottom

1-HPI 2-ROS 3-Phx 4-PE 5-Orders/Results 6-Assessment 7-Plan

What condition correct describes "dangerous infection of the appendix"?

Appendicitis

An elderly male patient has a history of an enlarged prostate. What PMHx would you record into the chart? (Use abbreviation)

BPH

What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"? Use abbreviation

CAD

What condition correctly describes "A blood clot in the extremities" Use abbreviation

DVT

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 establishes patient?

Established

T/F A family friend was recently evaluated for IDDM and lost his paperwork and does not know what medications he should be taking at home. He asks you to look up his medical record when you go to your shift today, giving you verbal permission to access his information. In this scenario, it is justifiable for you to use your EMR login to look up the important patient information.

False

T/F All symptoms documented in the ROS are also documented in the HPI

False

T/F It is acceptable to look up your own medical information while working in the clinic.

False

T/F One of your co-workers is having difficult printing a CT report and asks you to look up the report for them. You can look up the report as long as you do not read it.

False

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

T/F The ROS does not contain the CC is associated symptoms because they are already listed in the HPI.

False

T/F. The patient asks Scribe Salle to hold a patient's arm down so that she can finish suturing the patient. Sally is allowed to help because she is not interfering with the procedure.

False

What chronic condition would require diagnosis through a lipid panel? (Use abbreviation form)

HLD

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

Match the following description with the corresponding code.

ICD code=codes for diagnosis E&M code= codes for reimbursement HCC code= codes for risk

What condition correctly describes "heart attack"? (Use abbreviation)

MI

The patient reports a tenderness int heir right upper abdomen that began 2 weeks ago. Based on that information, do you document RUQ tenderness under the physical exam?

No

What condition correctly describes "blood clot in the lungs"? Use the abbreviation

PE

Which section of the chart should you document when you hear the following cue "what medical problems do you have?" -HPI -ROS -PHx -PE -ED Course Events -Diagnosis -Disposition

PHx

What condition correctly describes "A bacteria lung infection"? Use abbreviation

PNA

What is the medical term for "slow heart rate"?

bradycardia

What surgical procedure should be performed to diagnose CAD?

cardiac catheterization

Expand the following medical abbreviation. What does 'CP' stand for?

chest pain

What medical term describes the surgical removal of the gallbladder?

cholecystectomy

What medical term can be used to describe "having multiple chronic conditions"?

comorbidity

A patient requires a heart bypass to teat a heart attack. What PSHx would you record into the chart?

coronary artery bypass graft

What is the medical term for "open heart surgery"?

coronary artery bypass graft

A patient is s/p angioplasty with stand and quadruple cardiac bypass. What chronic condition should be included in their diagnosis today?

coronary artery disease

A patient underwent brain surgery to treat bleeding in the brain form a stroke. What PSHx would you record into the chart?

craniotomy

What chronic condition would require diagnosis through fasting blood glucose level or HbA1c?

diabetes mellitus

What is the medical term for difficulty breathing?

dyspnea

What medical term would describe a patient with a history of infection of inflammation of the liver?

hepatitis

Name the section based on the following clues: "This subjunctive section (from the patient's perspective) is where you document the story of the chief complaint and what brought the patient to see the doctor. Expand abbreviation

history of present illness

A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart?

hysterectomy

A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart?

mastectomy

A female patient underwent surgery to have her ovary removed. What PSHx would you record into the chart?

oophorectomy

An elderly female patient has a history of brittle bone disease and is at risk for developing bone fractures. What PMHx would you record into the chart?

osteoporosis

What medical term is used to describe the physician examining the patient by touch?

palpation

What medical term is used to describe the symptom of a patient's heart beating rapidly, irregularly, or forcibly?

palpitations

A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart?

partial lobectomy

What medical term would best describe "the likely course or outcome of a disease?"

prognosis

A female patient underwent surgery to have an ovary and fallopian tube removed. What PSHx would you record into the chart?

sapling-oophorectomy

What is the medical term for "pass out"?

syncope

You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "the pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam?

wrist- 2+ radial pulse top of foot- 2+ DP pulse neck- 2+ carotid pulse back of foot- 2+ PT pulse

What does PHI stand for?

Protected health information

What condition correctly describes "mini stroke". Use abbreviation

TIA

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? (Use abbreviation)

TURP

T/F Scribes should complete all charts by entering a scribe attestation before leaving the shift.

True

A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physical discusses 4-5 different back stretching exercises that the patient can perform every morning and before doing any heavy lifting. The discussion only taken 10 minutes of a 15 minute Established Patient visit. Would your physician be able to bill counseling time on this patient?

Yes

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

A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart?

angioplasty

A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P, and A respectively

5,2,2