Scribeamerica Outpatient Final exam | 100 Questions And Answers
Question: What medical term describes the surgical removal
of the gallbladder?
Correct answer: cholecystectomy
Question: What does the abbreviation "PHI" stand for?
Correct answer: Protected Health Information
Question: Is it true that sharing information about a case with
family is allowed, as long as you are scribing with the physician assigned to the case?
Correct answer: False
Question: What past surgical history (PSHx) would you
record into the chart for a patient underwent brain surgery to treat bleeding in the brain from a stroke?
Correct answer: craniotomy
Question: Is a patient considered a new patient or an
established patient if their primary care physician (PCP) is on vacation, they are scheduled to see the nurse practitioner (NP) who is covering for the PCP, and the patient has never been seen by the NP before?
Correct answer: Established
Question: Can a physician bill for counseling time if a patient
is diagnosed with back strain caused by heavy lifting, the physician discusses 4-5 different back stretching exercises for 10 minutes of a 15-minute Established Patient visit?
Correct answer: Yes
Question: What medical term best describes "the likely course
or outcome of a disease"?
Correct answer: Prognosis
Question: Which section of the chart should you document
when you hear the cue "what medical problems do you have"?
Correct answer: PHx
Question: Which HPI structure would be best to use for a
patient who presented for hyperlipidemia management but also reports recently experiencing urinary symptoms during the visit?
Correct answer: Multiple complaints structure
Question: 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 marketplace, or To require equal access, and opportunity, and affordability for health insurance plans by screening patient health information?
Correct answer: To require patient accountability in paying
for their health care visit
Question: What medical term would describe a patient with a
history of infection or inflammation of the liver?
Correct answer: Hepatitis
Question: For correct billing and reimbursement, what does a
counseling note require documentation of?
Correct answer: Total time with the patient, Percentage of
time spent counseling
Question: Which HPI structure would be best to use for a very
complex patient who has had multiple recent hospital admissions for lung cancer?
Correct answer: Chronologic structure
Question: What would be a valid complication for coronary
artery disease (CAD)?
Correct answer: MI
Question: Does the HPI for a 57-year-old male patient with
right lower quadrant abdominal pain that began 5 days ago while mowing the lawn, who took OTC Tylenol yesterday without relief, and has no nausea, vomiting, or diarrhea, meet Level 4 billing criteria?