PHI
Protected Health Information
Cholecystectomy
What medical term describes the surgical removal of the gallbladder?
False
T/F: Sharing
... [Show More] information about a case with family is allowed, as long as you are scribing with the physician assigned to the case.
Established
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 this NP before. Is the patient considered a new or established patient?
GERD
What is the medical abbreviation for the condition commonly described as "reflux"?
Prognosis
What medical term would best describe "the likely course or outcome of a disease"?
PHx
What section of the chart should you document when you hear the following cue "what medical problems do you have"?
Multiple complaints structure
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?
Chronological structure
You are writing an HPI for a very complex patient who has multiple recent hospital admissions for lung cancer. Which HPI structure would be the best to use in this scenario?
MI
Which of the following would be a valid complication for CAD?
Termination
Monetary fines to you and the hospital
Prison time
Lawsuit against you and the hospital
Violator is blacklisted from medical programs
Scribe program cancellation
What are the possible consequences of a HIPAA violation?
Health Insurance Portability and Accountability Act
What does HIPAA stand for?
Diabetes Mellitus
What chronic condition would require diagnosis through fasting blood glucose levels or HbA1c?
Yes, because the fever started soon after the cough
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?
Orders
Interpretations/results
Physical exam
Which of the following would be documented in the Objective section of the SOAP note?
Maintain patient privacy and confidentiality
HIPAA is a set of laws designed to ______.
PE
What is the medical abbreviation for the condition described as "blood clot in the lungs"?
HLD
What chronic condition would require diagnosis through a lipid panel?
Follow-up
Check-up
Medication refill
Lab results
Which of the following are considered non-reimbursable chief complaints?
False
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, is it justifiable for you to use your EMR login to look up the patient information.
Coronary Artery Disease
A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic condition should be included in their diagnosis today?
Waxing and waning
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 best describes the timing?
No
The patient reports a tenderness in their right upper abdomen that began 2 weeks ago. Based on that information, do you document RUQ tenderness under the physical exam?
MI
What condition correctly describes "heart attack"?
Tonsillectomy
A patient reportedly had their tonsils removed as a child. What PSHx would you record into the chart?
Tachycardia
What is the medical term for an elevated heart rate (over 100 bpm)?
Age and sex
PHx, if relevant
Diagnosis
Results
HPI
Prognosis/Plan
Identify what details are included in the following Assessment.
False
T/F: All symptoms documented in the ROS are also documented in the HPI
Coronary Artery Bypass Graft
What is the medical term for "open heart surgery"?
Respiratory: No respiratory distress, tachypnea, lungs are clear to auscultation bilaterally
Identify which of these PE systems contains contradictory findings:
Yes, because the phone is not an approved hospital device and it is not encypted
If a patient signs a waiver giving you permission to capture a photo of their unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo?
CAD
What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"?
Palpation
What medical term is used to describe the physician examining the patient by touch?
1. HPI
2. ROS
3. PE
4. Assessment
5. Plan
Organize the parts of the chart in order from top to bottom.
ENT
What ROS system would include dysphagia, the medical term for difficult or painful swallowing?
False
T/F: The ROS does not contain the CC and its associated symptoms because they are already listed in the HPI.
HEENT Throat: Pharyngeal erythema
HEENT Ears: TM erythema
Cardiovascular: Tachycardia
Pulmonary: Rhonchi
Abdomen: Murphy's sign
Neurological: Alert & oriented x4
Skin: Abscess with fluctuance
Match the body system with the corresponding PE finding:
Coronary Artery Bypass Graft
A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart?
Eyes
What body system would the exam finding PERRL be documented?
False
T/F: It is acceptable to look up your own medical information while working in the clinic.
TIA
What medical term correctly describes "mini-stroke"?
Angioplasty
A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart?
HTN
HLD
FHx of CAD under age 55
DM
Smoking
Which of the following are risk factors for developing CAD?
Bradycardia
What is the medical term for "slow heart rate"? [Show Less]