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FINAL EXAM – SCRIBE 2025 QUESTIONS
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What FHx/SHx information is usually asked for pediatric patients? - correct answer - Second hand smoke exposure Immunization status What is the medical term for "pass-out"? - correct answer - Syncope Which symptom(s) would a patient most likely present with if they had HLD? - correct answer - Asymptomatic T/F. Scribes should complete all charts by entering a scribe attestation before leaving the shift. - correct answer - True A 45 year old male presents to the clinic with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. He denies any accompanying dyspnea or diaphoresis. What elements are missing? - correct answer - 1. Modifying factor
- Relevant context
- Severity
A female patient underwent surgery to have her ovary removed. What PSHx would you record into the chart? - correct answer - Oophorectomy A patient comes into the clinic for a well woman exam. What type of clinic visit is this? - correct answer - Health management visit A patient has an E&M code of 99215. What information does this code give? - correct answer - LOS 5, Established patient Match the chronic condition with it's corresponding nonpharmacological treatment: DM - correct answer - Low carb diet, increase physical activity Match the chronic condition with it's corresponding nonpharmacological treatment: HTN - correct answer - Low sodium diet, decrease ETOH intake, increase physical activity
Which of the following details could be categorized as the HPI element context? - correct answer - Information regarding prior episodes, Information regarding prior evaluations, Information regarding risk factors Which symptom(s) would a patient most likely present with if they had asthma? - correct answer - Dyspnea A patient comes into the clinic for 3 weeks of a productive cough. What type of clinic visit is this? - correct answer - Diagnostic visit Which two codes should always be included on every superbill? - correct answer - E&M code, ICD code Which of the following would be valid complications for HTN? - correct answer - CRF, Impaired vision, CAD, CHF, MI What condition correctly describes "A bacterial lung infection"? - correct answer - Pneumonia A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart? - correct answer - Hysterectomy
T/F. The physician asks Scribe Sally to hold a patient's arm down so that she can finish suturing the patient. Sally is allowed to help because she is not interfering with the procedure. - correct answer - False What is the medical term for difficulty breathing? - correct answer - Dyspnea What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"? - correct answer - Genitourinary What surgical procedure should be performed to diagnose CAD? - correct answer - Angioplasty Can you document both "Clear breath sounds bilaterally" and "rhonchi in the right base"? Why or why not? - correct answer - No, because they contradict each other Murphy's sign is examined in which organ system? - correct answer - Abdomen
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? - correct answer - Yes What medical term would best describe "the likely course or outcome of a disease"? - correct answer - Prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have"? - correct answer - 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? - correct answer - Multiple complaints structure Which of the following is NOT a purpose of HITECH? - correct answer - 1. To require equal access, opportunity, and affordability for health insurance plans by screening patient health information
- To require government accountability on health insurance plans available in the market place
- To require encryption when using technology to transmit patient related information
- To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or inflammation of the liver? - correct answer - Hepatitis For correct billing and reimbursement to go through, a counseling note requires docuementation of the following: - correct answer - 1. 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? - correct answer - Chronologic Structure and Multiple complaints structure Which of the following would be valid complications for CAD? - correct answer - MI 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 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. - correct answer - Yes, it is level 4.
- Treatments
- Interpretations/results HIPAA is a set of laws designed to _______. - correct answer - maintain patient privacy and confidentiality What condition correctly describes "blood clot in the lungs"? - correct answer - PE MACRA - correct answer - Medicare Access and CHIP Reauthorization Act-government health care initiative that focuses on quality of care to improve patient outcomes MIPS - correct answer - Merit-based Incentive Payment System- system of payment which government funding is released if specific quality measures are tracked Quality Measures - correct answer - site specific health criteria that are tracked Patient with acute exacerbation of ESRD requiring emergency dialysis - correct answer - High risk
Patient with stable HTN and no other comorbities - correct answer - Low risk Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment - correct answer - Moderate risk What chronic condition would require diagnosis through a lipid panel? - correct answer - CVD cardiovascular disease Which of the following are considered non-reimbursable chief complaints? - correct answer - 1. Lab results
- Follow-up
- Medication refill
- Check-up What does "CP" stand for? - correct answer - Chest Pain 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, it is
Nephrolithiasis, stable - correct answer - 1. Pyelonephritis, resolved Nephrolithiasis, stabl
What condition correctly describes "heart attack"? - correct answer - MI An elderly male patient has a history of an enlarged prostate and has undergone surgery to treat his condition. What PSHx would you record into the chart? - correct answer - Benign Prostate Hyperplasia- What medical term is used to describe the symptom of a patient's heart beating rapidly, irregularly, or forcibly? - correct answer - Arrhythmia "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED." What details does this include? - correct answer - 1. Diagnosis
- Prognosis/Plan
- Age and sex
- PHx, if relevant
- HPI
- Results T/F. All symptoms documented in the ROS are also documented in the HPI. - correct answer - False What is the medical term for "open heart surgery"? - correct answer - Coronary Artery Bypass Graft T/F. A scribe does NOT need to document a problem list for patients that are young, healthy, and without any medical problems. - correct answer - False If a patient signs a waiver giving you permission to capture photo of their unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo? - correct answer - Yes because the phone is not an approved hospital device and it is not encrypted. What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"? - correct answer
A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? - correct answer - CABG A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. - correct answer - 5, 2, 2 T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they are included in the Problem List section. - correct answer - False T/F. It is acceptable to look up your own medical information while working in the clinic. - correct answer - False What condition correctly describes "mini-stroke"? - correct answer - TIA Which of the following are considered to be cardiac risk factors for CP patients? (cerebral Palsey) - correct answer - Family hx of CAD <55 y/o HLD CAD PSHx of CABG, angioplasty, and stent HTN
Tobacco use DM What is the medical term for "slow heart rate"? - correct answer - Bradycardia What can scribes in the clinic do to help accomplish MACRA and MIPS goals? - correct answer - 1. Document quality measures that are met by the physician during the visit.
- Use a trackingsheet to keep a track of patients that meet criteria for quality measures.
- Prompt the provider to perform a quality measure. "Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no visible signs of tonsilar exudate. Rapid strep negative." - correct answer - Brief Summary Which details are optional to include in a patient problem list? - correct answer - 1. Onset date
- Resolved date
- Note
Identify which of these selections contain contradictory physical exam findings.
- Back: CVA tenderness. Abdomen: no abdominal tenderness.
- Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact.
- Extremities: Non-tender. Skin: burning rash. Constitutional: No fever or chills. ENT: Copious rhinorrhea. - correct answer
- Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact. When should the word "lethargy" be documented on the chart? - correct answer - Only when the physician explicitly tells you to do so Why might it be important to document the presence of tears for pediatric or adult patients? - correct answer - Indicates the patient is hydrated Your physician tells you the patient has bibasilar crackles on exam. In which organ system would you document this physical exam finding? - correct answer - Respiratory
