ScribeAmerica Outpatient Final Exam

ScribeAmerica Outpatient Final Exam | 100 Questions and Answers (Verified Answers)

Question: What medical term describes the surgical removal

of the gallbladder?

Correct answer: cholecystectomy

Question: What does "PHI" stand for?

Correct answer: Protected Health Information

Question: True or False: 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 PSHx would you record into the chart for a

patient who 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 PCP is on vacation and they are scheduled to see an NP who is covering, whom they have never seen before?

Correct answer: Established

Question: Can a physician bill counseling time for a patient

diagnosed with back strain, where 10 minutes of a 15-minute Established Patient visit is spent discussing 4-5 back stretching exercises?

Correct answer: Yes

Question: What medical term best describes "the likely course

or outcome of a disease"?

Correct answer: Prognosis

Question: In 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 presenting for hyperlipidemia management who also reports recent urinary symptoms?

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 market place

• To require equal access, opportunity, and affordability for

health insurance plans by screening patient health information

Correct answer: a. To require patient accountability in paying

for their health care visit

Question: What medical term describes a patient with a

history of infection or inflammation of the liver?

Correct answer: Hepatitis

Question: What documentation is required for correct billing

and reimbursement of a counseling note?

Correct answer: Total time with the patient, Percentage of

time spent counseling

Question: Which HPI structure would be best for a very

complex patient with multiple recent hospital admissions for lung cancer?

Correct answer: Chronologic structure

Question: Which of the following would be a valid

complication for CAD?

Correct answer: MI

Question: Does the HPI for a 57-year-old male with RLQ

abdominal pain for 5 days, starting while mowing the lawn, with OTC Tylenol taken without relief and no nausea, vomiting, or diarrhea, meet Level 4 billing criteria?

Correct answer: Yes, the HPI meets Level 4 billing criteria