ScribeAmerica OP Final Exam Questions and
Answers.
* What medical term describes the surgical removal of the gallbladder? - ANS
cholecystectomy
What does "PHI" stand for? Expand the abbreviation. - 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. - ANS False
** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - ANS 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? - 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? - ANS Yes
What medical term would best describe "the likely course or outcome of a disease"? -
ANS Prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have"? - 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? - ANS
Multiple complaints structure
Which of the following is NOT a purpose of HITECH? - ANS - To require patient
accountability in paying for their health care visit
- 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
What medical term would describe a patient with a history of infection or inflammation of
the liver? - ANS Hepatitis
, For correct billing and reimbursement to go through, a counseling note requires
documentation of the following: - ANS - Total time with the patient
- Percentage of 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? - ANS Chronologic structure
Which of the following would be valid complications for CAD? - ANS MI
* 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. - ANS Yes, the HPI meets Level 4 billing criteria.
What are the possible consequences of a HIPAA violation? (select all that apply) - ANS
- Termination
-Monetary fines to you and the hospital
- Prison time
-Lawsuit against you and the hospital
-Violator is blacklisted from medical programs like Medical, PA, or NP school
- Scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. Remember, do not include any
spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good
luck ". - ANS Health Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? HINT: two words. Expand abbreviations. - ANS diabetes mellitus
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? - ANS Yes, because the fever started soon after
the cough
* Which of the following would be documented in the Objective section of the SOAP
note? (select all that apply.) - ANS - Orders
- Interpretations/results
- Treatments (that may involve medication or procedures)
- Physical exam
HIPAA is a set of laws designed to _______. (Select the best option.) - ANS maintain
patient privacy and confidentiality
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