FINAL EXAM SCRIBE AMERICA LATEST EXAM 150 REAL EXAM QUESTIONS AND CORRECT ANSWERS VERIFIED ANSWERS

What is the role of each person in the clinic? - ANSWER- Mid-level: works under the supervision of the physician to diagnose and treat patients Nurse/MA: records medical histories and sx; monitors the patients, completes meaningful use requirements, administers medication, assists with procedures. Receptionist: answers phone, schedules patient appointments, answers patients questions, provides patient with summary of visit with instructions from provider at checkout; organizes the patients paperwork's Scribe: documents the patients visit on behalf of the physician. What is the scope of a scribe? - ANSWER- An unlicensed person performing documentation and other non-clinical tasks under the direction of a healthcare provider. Are physician assistants and nurse practitioners considered medical providers? - ANSWER- No, they are mid-level provider. T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning purposes and under supervision of the physician. - ANSWERFALSE What will the scribe document for the outpatient visit? - ANSWERDocument the history, physical exam, results, procedures, assessment, and plan. Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine appointment with Dr. Heart. Is Lucy a new or established patient? - ANSWER- Established A patient made an appointment because she developed a rash a few days ago. What type of visit would this be? - ANSWER- Diagnostic A patient has an appointment for management of her diabetes. What type of visit would this be? - ANSWER- Health Management Who is the first person to speak with the patient after is he/she is placed in a room? - ANSWER- Physician What are the meaningful use requirements the nurse/MA will obtain? - ANSWER- Chief complaint, vital signs (HR, BP, T, RR), height, weight, BMI, smoking status What does H&P abbreviate and who perform this evaluation? - ANSWER- History and physical, physician evaluation Is a differential diagnosis necessary for a health management visit? - ANSWER- No, only for diagnostic visit. (Possible Dx that may be causing the symptoms) What information will be included in the patient's plan? Give three examples. - ANSWER- Follow-up with specialist if necessary, instructions for lifestyle and preventative care, and follow-up for next routine appointment. At what age would a family member's cardiac disease indicate an increased risk for similar heart disease in the patient? - ANSWERMI/CAD less than 55 y/o What are three common general family histories your physician may ask about? - ANSWER- HTN, DM, CA Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - ANSWER- Social History (SHx) Why must smoking status be documented on every patient 13 years and older? - ANSWER- Meaningful use requirement. Name the three most common routes of administration of illicit drugs. - ANSWER- oral, inhaled, injection The patient's mother states, "The daycare called me to pick up Angela and her brother because Angela had a fever." What are three items you can document under social history for Angela? - ANSWER- Mother (brought in and caretaker), goes to Daycare, has a brother. If a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered chronic? - ANSWER- No. An illness is typically classified as chronic when it lasts longer than 3months. What is a comorbidity? - ANSWER- Patients with comorbidities are complex in a number of ways: The treatment of one disease may affect or contradict the treatment of the second; adverse drug interactions; compounding symptoms may lead to poor compliance with treatment plan; if both illnesses affect a specific organ system, the patient is at increased risk of organ failure. Having multiple comorbidities increases the ________