ScribeAmerica OP Final Exam: Questions & Answers
What medical term describes the surgical removal of the gallbladder? Word Correct Ans - Cholecystectomy
What does "PHI" stand for? Expand the abbreviation Correct Ans - Protected Health Information
T/F Sharing inf...
Scribe Final Exam: Questions & Answers
What medical term describes the surgical removal of the gallbladder? Word
Correct Ans - Cholecystectomy
What does "PHI" stand for? Expand the abbreviation Correct Ans -
Protected Health Information
T/F Sharing information about a case with family is allowed, as long as you
are scribing with the physician assigned to the case Correct Ans - F
A patient underwent brain surgery to treat bleeding in the brain from a
stroke. What PSHx would you record into the chart? Correct Ans -
***NOT Hemorrhagic CVA
Craniotomy for hemorrhagic CVA
OR Craniotomy??
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?
Correct Ans - Established
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?
Correct Ans - Yes
What medical term would best describe "the likely course or outcome of a
disease"? Correct Ans - Prognosis
Which section of the chart should you document when you hear the following
cue "what medical problems do you have"? Correct Ans - PHx
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? Correct Ans - Multiple Complaint
structure
Which of the following is NOT a purpose of HITECH? Correct Ans - 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 patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or
inflammation of the liver? Correct Ans - Hepatitis
For correct billing and reimbursement to go through, a counseling note
requires documentation of the following: Correct Ans - Total time with
the patient
Percentage of the time spent counseling
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? Correct Ans - Chronologic Structure
Which of the following would be valid complications for CAD? Correct Ans
- MI
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. Correct Ans - Yes, the HPI meets Level 4
billing criteria
What are the possible consequences of a HIPAA violation? Correct Ans -
Lawsuit against you and the hospital
Monetary fines to you and the hospital
Scribe program cancellation
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