Scribe America Outpatient Class 5 + HIPAA Exam Questions and Answers
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Course
Scribe America outpatient
Institution
Scribe America Outpatient
What is the assessment? - Answer-diagnoses + summary of the visit
used by the provider as a "note to self" for any follow ups
What is ALWAYS included in the assessment? - Answer-age/sex of the patient
Diagnosis or differential diagnosis (ddx)
What else could be included in the assessment? -...
Scribe America Outpatient Class 5 +
HIPAA Exam Questions and Answers
What is the assessment? - Answer-diagnoses + summary of the visit
used by the provider as a "note to self" for any follow ups
What is ALWAYS included in the assessment? - Answer-age/sex of the patient
Diagnosis or differential diagnosis (ddx)
What else could be included in the assessment? - Answer-PMHx (if relevant), objective
info from the chart (PE, new results), subjective info (HPI elements for complex patients
What are the 2 requirements for a result to be included in the assessment? - Answer-1.
NEW (since the patient's last visit)
2. RELEVANT (relevant to today's diagnosis; could be a positive result or a negative
result that ruled out a diagnosis)
What is included when summarizing the test results? - Answer-NAME of the test,
RESULT of the test, WHY is was ordered
What is the plan? - Answer-list outlining how the doctor will treat and/or monitor the
patient
What information does the plan include? - Answer-- recommended treatments for each
diagnosis (lifestyle ∆, meds)
- prescriptions ordered today
- studies/labs/tests/imaging ordered today
- follow up with other healthcare professionals: Who/When
- follow up here: when
What is the structure of the plan? - Answer-bullet/numbered list
each diagnosis needs its own bullet
the last line should always include timeline for follow-up
What is ICD? - Answer-International Classification of Diseases
ICD code = diagnosis
What is the scribes main focus for billing? - Answer-Accurate Documentation
making sure all efforts made by the provider are documented
What are "Quality Measures"? - Answer-questionnaires and/or assessments providers
do to check risk and overall health of patients
used to study health trends in the population to better serve
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