SA Final

Which of the following is NOT a purpose of HITECH? (select all that apply)

1. To require patient accountability 2. To require government accountability 3. To require equal access

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. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you would type 0,0,0 with no spaces before or after the answer)

5,2,2

Which patient is high risk? A. Patient with acute exerbation of ESRD requiring emergency dialysis. B. Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment. C. Patient with stable HTN and no other comorbities.

A

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

D

What condition correctly describes "A blood clot in the extremities"? (HINT: Use the abbreviation form of the condition)

DVT (deep vein thrombosis)

What can scribes in the clinic do to help accomplish MACRA and MIPS goals? (Select all that apply.)

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

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

ENT

A patient has an E&M code of 99215. What information does this code give? (Select all that apply)

Established, LOS 5

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. 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

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

Genitourinary

The PE finding TM erythema is in which body system?

HEENT ears

The PE finding Pharyngeal Erythema is in which body system?

HEENT throat

What chronic condition would require diagnosis through a lipid panel? Use the abbreviation form. (Remember do not include extra spaces before or after your answer)

HLD

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

HPI, ROS, PHx, PE, Orders/Results, Assessment, Plan

What does HIPPA stand for?

Health Insurance Portability and Accountability Act

Name the section based on the following clues: "This subjective 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 the abbreviation.)

History of present illness

Which two codes should always be included on every superbill?

ICD, E&M

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

Indicates that the patient is hydrated

What condition correctly describes "heart attack"? (Use the abbreviated form of the condition)

MI

Which of the following would be valid complications for CAD? (Select all that apply)

MI

What three details should be included in a sentence summarizing results in the Assessment Section? (Select all that apply.)

Name of test, result of test, reason for why test was ordered

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.

No

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

No

Can you look up any patient report as long as you don't read it?

No (false)

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

Which of the following would be documented in the Objective section of the SOAP note? (select all that apply.

Orders, interpretations/results, treatments, physical exam

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

PHx

Which of the following information should you be including in the plan section when documenting? (Select all that apply.)

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

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

Respiratory

For correct billing and reimbursement to go through, a counseling note requires documentation of the following: (Select all that apply.)

Total time with patient, percentage of time spent counseling

What are scribes not allowed to do? (select all that are applicable)

Touch patients, perform clinical tasks, sign off on orders or prescriptions, authenticate the chart, transport patient specimens, give verbal orders, give CPR

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

Are you violating HIPPA by taking a photo of a patient's rash?

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

71 Murphy's sign is examined in which organ system?

abdomen

The PE finding murphy's sign is in which body system?

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, diagnosis, PHx, results, HPI, prognosis

A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart? (HINT: one word only. Remember, do not include any spaces before or after the term/phrase.)

angioplasty

What condition correctly describes "dangerous infection of the appendix"? (Do not use abbreviations. Remember, do not include any spaces before or after the term/phrase.)

appendicitis

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

back

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

bph (benign prostatic hyperplasia)

What is the medical term for "slow heart rate"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase)

bradycardia

Determine which structure best fits the following Assessment. "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

What surgical procedure should be performed to diagnose CAD?

cardiac catheterization

What does CP stand for?

chest pain

What medical term describes the surgical removal of the gallbladder? (Remember: when typing your answer, do not include any extra spaces before or after the term/phrase. For example: Correct way "Good luck" vs incorrect " good luck ".)

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?

chronological structure

ICD code

codes for diagnosis

E&M code

codes for reimbursement

HCC code

codes for risk

What medical term can be used to describe "having multiple chronic conditions"? (Remember do not include spaces before or after your answer.)

comorbidity

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

A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? (HINT: Expand the medical abbreviation.) Remember, do not include any extra spaces before or after the term/phrase.

coronary artery bypass graft

What is the medical term for "open heart surgery"? HINT: expand the abbreviation. (Remember: do not include any spaces before or after the term/phrase)

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? Expand the abbreviation. (Remember do not include spaces before or after your answer.)

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? (Remember, do not include any spaces before or after the term/phrase.)

craniotomy

What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? HINT: two words. Expand abbreviations. (Remember do not include spaces before or after your answer.)

diabetes mellitus

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? Hint: one word only

dyspnea

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

dyspnea

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? (view)1

established

What body system would the exam finding PERRL be documented in?

eyes

Which of the following are considered non-reimbursable chief complaints? (Select all that apply.)

follow-up, check-up, medication refill, lab results

MACRA

government healthcare initiative that focuses on quality of care to improve patient outcomes

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? (Remember: do not include any extra spaces before or after the term/phrase)

hepatitis

A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

hysterectomy

HIPPA is a set of laws designed to _

maintain patient privacy and confidentiality

A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

mastecomy

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

The PE finding alert and oriented is in which body system?

neurological

A female patient underwent surgery to have her ovary removed. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

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? (Remember, do not include any spaces before or after the term/phrase.)

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?

palpitation

A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (HINT: two words. Remember, do not include any spaces before or after the term/phrase.)

partial lobectomy

What condition correctly describes "blood clot in the lungs"? (Use the abbreviation form of the condition)

pe

What condition correctly describes "A bacterial lung infection"? (HINT: Use the abbreviation form of the condition.

pna

Which of the following details could be categorized as the HPI element context? (Select all that apply)

prior episodes, prior evaluations, risk factors

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"? (Remember do not include spaces before or after your answer.)

prognosis

What does PHI stand for?

protected health information

The PE finding rhonchi is in which body system?

pulmonary

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?

radial, dorsalis pedis, carotid, posterior tibial

A female patient underwent surgery to have an ovary and fallopian tube removed. What PSHx would you record into the chart? (Remember, do not include any spaces before or after the term/phrase.)

salpingo-oophorectomy

What FHx/SHx information is usually asked for pediatric patients? (Select all that apply)

secondhand smoke and immunization status

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.)

severity, modifying factor, relevant context

Quality Measures

site specific health criteria that are tracked

The PE finding abscess with fluctuance is in which body system?

skin

What is the medical term for "pass-out"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase.)

syncope

MIPS

system of payment in which government funding is released if specific quality measures are tracked

What condition correctly describes "mini-stroke"? (Use the abbreviation form of the condition. Remember, do not include any spaces before or after the term/phrase.)

tia

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

true

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 the abbreviation form. Remember, do not include any spaces before or after the term/phrase.)

turp ( Transurethral resection of the prostate)

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

What are the possible consequences of a HIPAA violation? (select all that apply)

All of the above

Which of the following are considered to be cardiac risk factors for CP patients? (select all that apply)

All of the above

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

Asymptomatic

Which patient is moderate risk? A. Patient with acute exerbation of ESRD requiring emergency dialysis. B. Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment. C. Patient with stable HTN and no other comorbities.

B.

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

C.

Which patient is low risk? A. Patient with acute exerbation of ESRD requiring emergency dialysis. B. Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment. C. Patient with stable HTN and no other comorbities.

C.

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

CAD

Which of the following would be valid complications for HTN? (Select all that apply.)

CHF, MI, CRF, impaired vision, CAD

The PE finding tachycardia is in which body system?

Cardiovascular