Docsity
Log inSign up
Docsity
Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity

Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips
Guidelines and tips
Sell on Docsity
Sell on Docsity
Log inSign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources
Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents
download point icon20 Points

For each uploaded document

Answer questions
download point icon5 Points

For each given answer (max 1 per day)

All the ways to get free points
Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study
Go to the blog

Medical Terminology and Concepts for Scribes: Final Exam Questions and Answers, Exams of Nursing

Computer Systems Institute (CSI)Nursing

A comprehensive set of questions and answers covering essential medical terminology and concepts relevant to the role of a scribe. It covers topics such as medical terms, patient history documentation, billing procedures, and hipaa compliance. Designed to help aspiring scribes prepare for their final exam and gain a deeper understanding of the medical field.

Typology: Exams

2024/2025

Available from 03/03/2025

N-U-R-S-E
N-U-R-S-E ๐Ÿ‡บ๐Ÿ‡ธ

2

(2)

3.3K documents

1 / 22

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
P a g e | 1
FINAL EXAM โ€“ SCRIBE 2025 QUESTIONS
AND VERIFIED SOLUTIONS| ABSOLUTE
SUCCESS GUARANTEED.
1. What medical term describes the surgical removal of the
gallbladder? - Correct Answer-Cholecystectomy
2. What does "PHI" stand for? - Correct Answer-Protected Health
Information
3. T/F. 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
4. A patient underwent brain surgery to treat bleeding in the brain
from a stroke. What PSHx would you record into the chart? -
Correct Answer-Craniotomy
5. 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
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16

Partial preview of the text

Download Medical Terminology and Concepts for Scribes: Final Exam Questions and Answers and more Exams Nursing in PDF only on Docsity!

FINAL EXAM โ€“ SCRIBE 2025 QUESTIONS

AND VERIFIED SOLUTIONS| ABSOLUTE

SUCCESS GUARANTEED.

  1. What medical term describes the surgical removal of the gallbladder? - Correct Answer-Cholecystectomy
  2. What does "PHI" stand for? - Correct Answer-Protected Health Information
  3. T/F. 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
  4. A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Correct Answer-Craniotomy
  5. 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? - Correct Answer-Established

  1. 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? - Correct Answer-Yes
  2. What medical term would best describe "the likely course or outcome of a disease"? - Correct Answer-Prognosis
  3. Which section of the chart should you document when you hear the following cue "what medical problems do you have"? - Correct Answer-PHx
  4. 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

Correct Answer-Chronologic Structure and Multiple complaints structure

  1. Which of the following would be valid complications for CAD? - Correct Answer-MI
  2. Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a NEW patient:
  3. 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.
  4. What are the possible consequences of a HIPAA violation? - Correct Answer-1. Scribe program cancellation
    1. Prison time
    1. Termination
    1. Violator is blacklisted from medical programs like Medical, PA, or NP school
    1. Monetary fines to you and the hospital
    1. Lawsuit against you and the hospital
  1. What does HIPAA stand for? - Correct Answer-Health Insurance Portability and Accountability Act
  2. What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? - Correct Answer- Diabetes
  3. 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? - Correct Answer-Yes, because the fever started soon after the cough
  4. Which of the following would be documented in the Objective section of the SOAP note? - Correct Answer-1. Orders
    1. Physical Exam
    1. Treatments
    1. Interpretations/results
  8. HIPAA is a set of laws designed to _______. - Correct Answer-maintain patient privacy and confidentiality
  1. Asthmatic patient with acute acerbation that is resolve in office with nebulizer treatment - Correct Answer-Moderate risk
  2. What chronic condition would require diagnosis through a lipid panel? - Correct Answer-CVD cardiovascular disease
  3. Which of the following are considered non-reimbursable chief complaints? - Correct Answer-1. Lab results
    1. Follow-up
    1. Medication refill
    1. Check-up
  7. What does "CP" stand for? - Correct Answer-Chest Pain
  8. 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 justifiable for you to use your EMR login to look up the important patient information. - Correct Answer-False
  1. What condition correctly describes "dangerous infection of the appendix"? - Correct Answer-Appendicitis
  2. An elderly male patient has a history of an enlarged prostate. What PMHx would you record into the chart? - Correct Answer- BPH-Benign Prostatic Hyperplasia
  3. A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic condition should be included in their diagnosis today? - Correct Answer-Coronary Artery Disease
  4. 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 would best describe the Timing? - Correct Answer-Waxing and waning
  5. Which of the following would be included in a Problem List?
  6. Family hx of renal cancer
  7. Pyelonephritis, resolved

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."

  1. What details does this include? - Correct Answer-1. Diagnosis
    1. Prognosis/Plan
    1. Age and sex
    1. PHx, if relevant
    1. HPI
    1. Results
  7. T/F. All symptoms documented in the ROS are also documented in the HPI. - Correct Answer-False
  8. What is the medical term for "open heart surgery"? - Correct Answer-Coronary Artery Bypass Graft
  9. 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
  1. 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.
  2. What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"? - Correct Answer-CAD
  3. An elderly female patient has a history of brittle bone disease and is at risk for developing bone fractures. What PMHx would you record into the chart? - Correct Answer-Bone Fx
  4. Organize the parts of the chart in order from top (1) to bottom (7). - Correct Answer-1. HPI
    1. ROS
    1. PMHx
    1. PE
    1. Orders/Results
    1. Assessment
    1. Plan
  1. T/F. It is acceptable to look up your own medical information while working in the clinic. - Correct Answer-False
  2. What condition correctly describes "mini-stroke"? - Correct Answer-TIA
  3. 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
  4. HLD
  5. CAD
  6. PSHx of CABG, angioplasty, and stent
  7. HTN
  8. Tobacco use
  9. DM
  10. What is the medical term for "slow heart rate"? - Correct Answer-Bradycardia
  1. 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.
    1. Use a trackingsheet to keep a track of patients that meet criteria for quality measures.
    1. Prompt the provider to perform a quality measure.
  4. "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
  5. Which details are optional to include in a patient problem list? - Correct Answer-1. Onset date
    1. Resolved date
    1. Note
  8. What condition correctly describes "A blood clot in the extremities"? - Correct Answer-DVT- deep vein thrombosis
  9. A patient requires removal of the breast to treat breast cancer. What PSHx would you record into the chart? - Correct Answer-Mastectomy
  1. Immunization status
  2. What is the medical term for "pass-out"? - Correct Answer- Syncope
  3. Which symptom(s) would a patient most likely present with if they had HLD? - Correct Answer-Asymptomatic
  4. T/F. Scribes should complete all charts by entering a scribe attestation before leaving the shift. - Correct Answer-True
  5. 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
    1. Relevant context
    1. Severity
  1. A female patient underwent surgery to have her ovary removed. What PSHx would you record into the chart? - Correct Answer-Oophorectomy
  2. A patient comes into the clinic for a well woman exam. What type of clinic visit is this? - Correct Answer-Health management visit
  3. A patient has an E&M code of 99215. What information does this code give? - Correct Answer-LOS 5, Established patient
  4. Match the chronic condition with it's corresponding nonpharmacological treatment:
  5. DM - Correct Answer-Low carb diet, increase physical activity
  6. Match the chronic condition with it's corresponding nonpharmacological treatment:
  7. HTN - Correct Answer-Low sodium diet, decrease ETOH intake, increase physical activity
    1. Reason for why the test was ordered
    1. Result of test
  3. Which of the following details could be categorized as the HPI element context? - Correct Answer-Information regarding prior episodes, Information regarding prior evaluations,
  4. Information regarding risk factors
  5. Which symptom(s) would a patient most likely present with if they had asthma? - Correct Answer-Dyspnea
  6. A patient comes into the clinic for 3 weeks of a productive cough. What type of clinic visit is this? - Correct Answer- Diagnostic visit
  7. Which two codes should always be included on every superbill? - Correct Answer-E&M code, ICD code
  8. Which of the following would be valid complications for HTN? - Correct Answer-CRF, Impaired vision, CAD, CHF, MI
  1. What condition correctly describes "A bacterial lung infection"? - Correct Answer-Pneumonia
  2. A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart? - Correct Answer-Hysterectomy
  3. 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
  4. What is the medical term for difficulty breathing? - Correct Answer-Dyspnea
  5. What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"? - Correct Answer-Genitourinary