ScribeAmerica Outpatient Final Practice Questions And Complete Solutions
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Course
Outpatient Scribe America
Institution
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...
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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