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Exam (elaborations)

ScribeAmerica Outpatient Final Practice Questions And Complete Solutions

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  • Outpatient Scribe America
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  • Outpatient Scribe America

What will the scribe document for the outpatient visit? - ANSWER Important notes for past medical records History and Physical Laboratory and radiology results Physician Interpretation of XRs and EKGs Assessment and Plan Who is the first person to speak with the patient after he/she is pl...

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  • August 22, 2024
  • 9
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Outpatient Scribe America
  • Outpatient Scribe America
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Victoria108
ScribeAmerica Outpatient Final Practice Questions
And Complete Solutions
What will the scribe document for the outpatient visit? - ANSWER Important notes for past medical
records

History and Physical

Laboratory and radiology results

Physician Interpretation of XRs and EKGs

Assessment and Plan



Who is the first person to speak with the patient after he/she is placed in the room? - ANSWER Nurse or
MA



What are the meaningful use requirements the nurse or MA will obtain? - ANSWER Vital Signs (BP, RR,
HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status



What does H&P abbreviate and who performs this evaluation? - ANSWER History and Physical,
physician



Is a differential diagnosis necessary for a health maintenance visit? - ANSWER No, only for a diagnostic
visit



What information will be included in the patient's plan? - ANSWER Specialist follow-up, instructions for
lifestyle and preventative care, routine follow-up



The CBC shows anemia - ANSWER Results



The EKG shows NSR - ANSWER Results



The pt came to the clinic for chest pain - ANSWER HPI/ROS

, The pt also stubbed his toe last week - ANSWER HPI/ROS



The pt is in no acute distress - ANSWER Physical Exam



The pt has suffered from HTN for many years - ANSWER PMHx



Thee is tenderness of the RUQ - ANSWER PE



The pt's mother has heart disease - ANSWER FHX



The diagnosis is upper respiratory infection - ANSWER Assessment



The pt will be prescribed penicillin today - ANSWER Plan



What age would a family member's cardiac disease indicate an increased risk for similar heart disease in
the pt? - ANSWER <55 y/o



What are three common general FHx your physician may ask about? - ANSWER HTN, CA, DM



Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section? - ANSWER
Yes



Why must smoking status be documented on every patient 13 years and older? - ANSWER Meaningful
use requirements



HIPPA Rule 1 - ANSWER If a patient is not assigned to your doctor, do not touch the chart



HIPAA Rule 2 - ANSWER There is always someone watching



HIPAA Rule 3 - ANSWER Never share your username or password

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