final exam- scribe

What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"?

Genitourinary

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

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

Health management visit

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

Hepatitis

Patient with acute exacerbation of ESRD requiring emergency dialysis

High risk

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

Hysterectomy

Why might it be important to document the presence of tears for pediatric or adult patients?

Indicates the patient is hydrated

Which of the following details could be categorized as the HPI element context?

Information regarding prior episodes, Information regarding prior evaluations, Information regarding risk factors

A patient has an E&M code of 99215. What information does this code give?

LOS 5, Established patient

Match the chronic condition with it's corresponding nonpharmacological treatment: DM

Low carb diet, increase physical activity

Match the chronic condition with it's corresponding nonpharmacological treatment: HLD

Low fat diet, increase physical activity

Patient with stable HTN and no other comorbities

Low risk

Match the chronic condition with it's corresponding nonpharmacological treatment: HTN

Low sodium diet, decrease ETOH intake, increase physical activity

What condition correctly describes "heart attack"?

MI

Which of the following would be valid complications for CAD?

MI

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

Mastectomy

MACRA

Medicare Access and CHIP Reauthorization Act-government health care initiative that focuses on quality of care to improve patient outcomes

MIPS

Merit-based Incentive Payment System- system of payment which government funding is released if specific quality measures are tracked

Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment

Moderate risk

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?

Multiple complaints structure

Can you document both "Clear breath sounds bilaterally" and "rhonchi in the right base"? Why or why not?

No, because they contradict each other

When should the word "lethargy" be documented on the chart?

Only when the physician explicitly tells you to do so

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

Oophorectomy

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

PE

Which section of the chart should you document when you hear the following cue "what medical problems do you have"?

PHx

What condition correctly describes "A bacterial lung infection"?

Pneumonia

A modifier code usually gives information about which type of code?

Procedure code

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

Prognosis

What does "PHI" stand for?

Protected Health Information

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

Respiratory

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

Salpingectomy

What FHx/SHx information is usually asked for pediatric patients?

Second hand smoke exposure Immunization status

What is the medical term for "pass-out"?

Syncope

What condition correctly describes "mini-stroke"?

TIA

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

True

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?

Waxing and waning

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?

Yes

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 and it is not encrypted.

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

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.

Yes, it is level 4.

A positive straight-leg-raise may indicate herniated discs. Which organ system should this PE finding be documented in?

back

ICD code

codes for diagnosis

E&M code

codes for reimbursement

HIPAA is a set of laws designed to _______.

maintain patient privacy and confidentiality

Quality Measures

site specific health criteria that are tracked

"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." What details does this include?

1. Diagnosis 2. Prognosis/Plan 3. Age and sex 4. PHx, if relevant 5. HPI 6. Results

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

1. Document quality measures that are met by the physician during the visit. 2. Use a trackingsheet to keep a track of patients that meet criteria for quality measures. 3. Prompt the provider to perform a quality measure.

Organize the parts of the chart in order from top (1) to bottom (7).

1. HPI 2. ROS 3. PMHx 4. PE 5. Orders/Results 6. Assessment 7. Plan

Which of the following are considered non-reimbursable chief complaints?

1. Lab results 2. Follow-up 3. Medication refill 4. Check-up

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?

1. Modifying factor 2. Relevant context 3. Severity

What three details should be included in a sentence summarizing results in the Assessment Section?

1. Name of test 2. Reason for why the test was ordered 3. Result of test

Which details are optional to include in a patient problem list?

1. Onset date 2. Resolved date 3. Note

Which of the following would be documented in the Objective section of the SOAP note?

1. Orders 2. Physical Exam 3. Treatments 4. Interpretations/results

Which of the following would be included in a Problem List? Family hx of renal cancer Pyelonephritis, resolved Hx of renal stone extraction Nephrolithiasis, stable

1. Pyelonephritis, resolved Nephrolithiasis, stabl 2.

What are the possible consequences of a HIPAA violation?

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

Which of the following is NOT a purpose of HITECH?

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

For correct billing and reimbursement to go through, a counseling note requires docuementation of the following:

1. Total time with the patient 2. Percentage of time spent counseling

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

Murphy's sign is examined in which organ system?

Abdomen

What surgical procedure should be performed to diagnose CAD?

Angioplasty

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

Appendicitis

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

Arrhythmia

Which symptom(s) would a patient most likely present with if they had HLD?

Asymptomatic

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

BPH-Benign Prostatic Hyperplasia

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?

Benign Prostate Hyperplasia-

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?

Bone Fx

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

Bradycardia

"Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no visible signs of tonsilar exudate. Rapid strep negative."

Brief Summary

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

CABG

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

CAD

Which of the following would be valid complications for HTN?

CRF, Impaired vision, CAD, CHF, MI

What chronic condition would require diagnosis through a lipid panel?

CVD cardiovascular disease

What does "CP" stand for?

Chest Pain

What medical term describes the surgical removal of the gallbladder?

Cholecystectomy

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?

Chronologic Structure and Multiple complaints structure

HCC code

Codes for risk

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."

Comprehensive summary

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

Coronary Artery Bypass Graft

A patient is s/p angioplasty with stent 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 from a stroke. What PSHx would you record into the chart?

Craniotomy

What condition correctly describes "A blood clot in the extremities"?

DVT- deep vein thrombosis

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

Diabetes

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

Diagnostic visit

What is the medical term for difficulty breathing?

Dyspnea

Which symptom(s) would a patient most likely present with if they had asthma?

Dyspnea

Which two codes should always be included on every superbill?

E&M code, ICD code

What ROS system would include dysphagia, the medical term for difficult or painful swallowing?

ENT

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?

Established

Identify which of these selections contain contradictory physical exam findings. 1. Back: CVA tenderness. Abdomen: no abdominal tenderness. 2. Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact. 3. Extremities: Non-tender. Skin: burning rash. Constitutional: No fever or chills. ENT: Copious rhinorrhea.

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

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. A scribe does NOT need to document a problem list for patients that are young, healthy, and without any medical problems.

False

T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they are included in the Problem List section.

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 difficulty 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. Resolved problems may be deleted from the problem list.

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 and its associated symptoms because they are already listed in the HPI.

False

T/F. The physician asks Scribe Sally 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

Which of the following are considered to be cardiac risk factors for CP patients? (cerebral Palsey)

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