ScribeAmerica - FINAL EXAM - GENERAL OP Score 80%-90% to Pass!
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Course
ScribeAmerica
Institution
ScribeAmerica
Cholecystectomy
What medical term describes the surgical removal of the gallbladder?
Protected Health Information
What does PHI stand for? Expand the abbreviation.
00:05
01:23
False
T/F Sharing information about a case with family is allowed, as long as you are scribing with ...
ScribeAmerica - FINAL EXAM - GENERAL OP Score 80%-90% to Pass!
Cholecystectomy - Answer What medical term describes the surgical removal of the gallbladder?
Protected Health Information - Answer What does PHI stand for? Expand the abbreviation.
False - Answer T/F Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case.
Craniotomy - Answer A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record in the chart?
Established - Answer 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 establish patient?
Yes - Answer 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?
Prognosis - Answer What medical term would best describe " the likely course or outcome of a disease?"
PHx - Answer What section of the chart should you document when you hear the following cue "what medical problems do you have?"
Multiple Complaints Structure - Answer 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?
❌ require patient accountability in paying for their health care visit (select)
✅ require patient privacy and confidentiality ❌ require government accountability on health insurance plans available in the market place (select)
❌ require equal access, opportunity, and affordability for health insurance plans by screening patient health information (select)
✅ require encryption when using technology to transmit patient related information - Answer Which of the following is NOT A PURPOSE OF HITECH select all that apply
Hepatitis - Answer What medical term would describe a patient with a history of infection or inflammation of the liver?
Total time with the patient
Percentage of time spent counseling - Answer For correct billing and reimbursement to go through, a counseling note requires documentation of the following
Chronologic Structure - Answer 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?
MI - Answer Which of the following would be valid complications for CAD?
Yes, the HPI meets Level 4 billing criteria. - Answer Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a new patient.
57 year old male patient presented with a 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.
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 - Answer What are the possible consequences of a HIPAA violation?
Health Insurance Portability and Accountability Act - Answer What does HIPAA stand for? Expand the abbreviation
Diabetes Mellitus - Answer What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? two words expand abbreviation
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