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ScribeAmerica OP Final Exam|Updated|Rated A+|Verified|2024
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ScribeAmerica OP Final Exam|Updated|Rated A+|Verified|
2024
* What medical term describes the surgical removal of the gallbladder? -
-cholecystectomy
-What does "PHI" stand for? Expand the abbreviation. - -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. - -False
-** A patient underwent brain surgery to treat bleeding in the brain
from a stroke. What PSHx would you record into the chart? - -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? - -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? - -Yes
-What medical term would best describe "the likely course or outcome
of a disease"? - -Prognosis
-Which section of the chart should you document when you hear the
following cue "what medical problems do you have"? - -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? - -Multiple complaints structure
-Which of the following is NOT a purpose of HITECH? - -- 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? - -Hepatitis
-For correct billing and reimbursement to go through, a counseling note
requires documentation of the following: - -- 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? - -Chronologic structure
-Which of the following would be valid complications for CAD? - -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. - -Yes, the HPI
meets Level 4 billing criteria.
-What are the possible consequences of a HIPAA violation? (select all
that apply) - -- 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 ". - -Health Insurance Portability
and Accountability Act
-What chronic condition would require diagnosis through fasting blood
glucose level or HbA1c? HINT: two words. Expand abbreviations. - -
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? - -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.) - -- Orders
- Interpretations/results
- Treatments (that may involve medication or procedures)
- Physical exam
-HIPAA is a set of laws designed to _______. (Select the best option.) - -
maintain patient privacy and confidentiality
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