PHI - ANSWER-Protected Health Information
Cholecystectomy - ANSWER-What medical term describes the surgical removal of the gallbladder?
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.
Establis...
Cholecystectomy - ANSWER-What medical term describes the surgical removal of the
gallbladder?
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.
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 this NP before. Is the patient considered a new or established patient?
GERD - ANSWER-What is the medical abbreviation for the condition commonly
described as "reflux"?
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?
Chronological structure - ANSWER-You are writing an HPI for a very complex patient
who has 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 a valid complication for CAD?
Termination
Monetary fines to you and the hospital
Prison time
Lawsuit against you and the hospital
Violator is blacklisted from medical programs
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?
Diabetes Mellitus - ANSWER-What chronic condition would require diagnosis through
fasting blood glucose levels or HbA1c?
Yes, because the fever started soon after the cough - ANSWER-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?
Orders
Interpretations/results
Physical exam - ANSWER-Which of the following would be documented in the
Objective section of the SOAP note?
Maintain patient privacy and confidentiality - ANSWER-HIPAA is a set of laws designed
to ______.
PE - ANSWER-What is the medical abbreviation for the condition described as "blood
clot in the lungs"?
HLD - ANSWER-What chronic condition would require diagnosis through a lipid panel?
Follow-up
Check-up
Medication refill
Lab results - ANSWER-Which of the following are considered non-reimbursable chief
complaints?
False - ANSWER-T/F: A family friend was recently evaluated for IDDM and lost his
paperwork and does not know what medications he should be taking at home. He asks
you to look up his medical record when you go to your shift today, giving you verbal
permission to access his information. In this scenario, is it justifiable for you to use your
EMR login to look up the patient information.
Coronary Artery Disease - ANSWER-A patient is s/p angioplasty with stent and
quadruple cardiac bypass. What chronic condition should be included in their diagnosis
today?
Waxing and waning - ANSWER-A patient states that he has been having abdominal
pain for the last three days, and it varies between mild and severe. Which of the
following best describes the timing?
No - ANSWER-The patient reports a tenderness in their right upper abdomen that
began 2 weeks ago. Based on that information, do you document RUQ tenderness
under the physical exam?
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