6 Scribe America OP Final Exam with 100% Correct Answers 2023-2024, Exams of Nursing

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QUESTIONS AND ANSWERS

6 Scribe America OP Final Exam with 100% Correct

Answers 2023- 2024

TESTED AND CONFIRMED A+ ANSWERS

cholecystectom y

What medical term describes the surgical removal of the gallbladder? - Correct answer-

Informatio

n

What does "PHI" stand for? Expand the abbreviation. - Correct answer-Protected Health

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

What medical term would best describe "the likely course or outcome of a disease"? - Correct

answer-Prognosis

PSHx would you record into the chart? - Correct answer-craniotomy

** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What

Establis hed

patient considered a new patient or an established patient? - Correct 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 the NP before. Is this

What are the possible consequences of a HIPAA violation? (select all that apply) -

Quality Measures - Correct answer-site specific health criteria that are tracked

• 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,

the HPI meets Level 4 billing criteria.

Correct answer-- Termination

• Monetary fines to you and hthoespital
• Prison time
• Lawsuit against you and theshpoital
• Violator is blacklisted fromdmiceal programs like Medical, PA, or NP school
• Scribe program cancellation

What does HIPAA stand for? Expand the abbreviation. Remember, do not include any

spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good

luck ". - Correct answer-Health Insurance Portability and Accountability Act

maintain patient privacy and confidentiality

HIPAA is a set of laws designed to. (Select the best option.) - Correct answer-

of the condition) - Correct answer-PE

What condition correctly describes "blood clot in the lungs"? (Use the abbreviation form

care to improve patient outcomes.

• MACRA - Correct answer-government healthcare initiative that focuses on quality of

specific quality measures are tracked

• MIPS - Correct answer-system of payment in which government funding is released if

High Risk - Correct answer-

Moderate Risk - Correct answer-

Low Risk - Correct answer-

rect

ll

CP - Correct answer-chest pain

answer-- Follow-up

• Check-up

• Which of the following are considered non-reimbursable chief complaints? - Cor

• Lab results
• Medication refi

abbreviation form. - Correct answer-HLD

What chronic condition would require diagnosis through a lipid panel? Use the

• Correct answer-waxing and waning

varies between mild and severe. Which of the following would best describe the Timing?

A patient states that he has been having abdominal pain for the last three days, and it

exam? - Correct answer-No

Based on that information, do you document RUQ tenderness under the physical

The patient reports a tenderness in their right upper abdomen that began 2 weeks ago.

48 - Correct answer-

Organize the parts of the chart in order from top (1) to bottom (7). - Correct answer-1.

HPI

• DM (can cause severe bleeding. Have to know DM for my clinic)

CA

D

• PSHx of CABG, angioplasty, and stent
• Family hx

of

CAD <

y/o

HL

D

all that apply) - Correct answer-- HTN

Which of the following are considered to be cardiac risk factors for CP patients? (select

7. Plan
8. Assessment
9. Orders/Results

4. PE

3. PHx

2. ROS

swallowing? - Correct answer-ENT

What ROS system would include dysphagia, the medical term for difficult or painful

already listed in the HPI. - Correct answer-F (bc anything in hpi will be in ros)

T/F. The ROS does not contain the CC and its associated symptoms because they are

the chart? (HINT: one word only.) - Correct answer-angioplasty

A patient requires a "balloon" to treat a heart attack. What PSHx would you record into

• tobacco

use

Determine which structure best fits the following Assessment.

bradycaridi a

do not include any spaces before or after the term/phrase) - Correct answer-

What is the medical term for "slow heart rate"? (Remember, when typing your answer,

for death and other complications if he does not seek further urgent medical attention.

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

"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation

• Determine which structure best fits the following Assessment.

Correct answer-comorbidities

What medical term can be used to describe "having multiple chronic conditions"? -

record into the chart? (HINT: two words) - Correct answer-partial lobectomy

A patient requires partial removal of the lung to treat lung cancer. What PSHx would you

What can scribes in the clinic do to help accomplish MACRA and MIPS goals? - Correct

answer-- Document quality measures that are met by the physician during the visit.

• Prompt the provider to perform a quality measure.
• Use a trackingsheet to keep a track of patients that meet criteria for quality measures.

abbreviation form of the condition) - Correct answer-DVT

What condition correctly describes "A blood clot in the extremities"? (HINT: Use the

3. HCC code - Correct answer-1) codes for diagnosis

4. codes for reimbursement

5. code for risk

6. E&M code

7. ICD code

CPR

Correct answer- F

up the report for them. You can look up the report as long as you do not read it. -

T/F. One of your co-workers is having difficulty printing a CT report and asks you to look

after the term/phrase.) - Correct answer-salpingo-oophorectomy

PSHx would you record into the chart? (Remember, do not include any spaces before or

A female patient underwent surgery to have an ovary and fallopian tube removed. What

Procedure

code

• A modifier code usually gives information about which type of code? - Correct answer-

What three details should be included in a sentence summarizing results in the Assessment Section?

(Select all that apply.) - Correct answer-- Name of the test

Which two codes should always be included on every superbill? - Correct answer-- ICD

co

de

• E&M

code

• Which of the following would be valid complications for HTN? (Select all that apply.) -

Correct answer--

CHF

M I

CR F

• Impaired

vision

CA

D

Which of the following information should you be including in the plan section when

abbreviation form of the condition.) - Correct answer-PNA

• What condition correctly describes "A bacterial lung infection"? (HINT: Use the

88 - Correct answer-

What is the medical term for difficulty breathing? - Correct answer-Dyspnea

• Prescription for diagnostic study (referral)

documenting? (Select all that apply.) - Correct answer-- Prescription for medication

record into the chart? - Correct answer-Hysterectomy

A female patient underwent surgery to have her uterus removed. What PSHx would you

procedure. - Correct answer-F

suturing the patient. Sally is allowed to help because she is not interfering with the

T/F. The physician asks Scribe Sally to hold a patient's arm down so that she can finish

or prolonged vaginal bleeding"? - Correct answer-Genitourinary

What ROS system would include menorrhagia, the medical term for "abnormally heavy

grossly

intact.

answer-Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves

Identify which of these selections contain contradictory physical exam findings. - Correct

when the physician explicitly tells you to do so

When should the word "lethargy" be documented on the chart? - Correct answer-Only

patients? - Correct answer-Indicates that the patient is hydrated

Why might it be important to document the presence of tears for pediatric or adult

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

Name the section based on the following clues: "This subjective section (from the

patient's perspective) is where you document the story of the chief complaint and what brought the

patient to see the doctor." (Expand the abbreviation.) - Correct answer-