Medical Terminology and Healthcare Practices, Exams of Nursing

Download Medical Terminology and Healthcare Practices and more Exams Nursing in PDF only on Docsity! Scribe America Final Exam with 100% verified solutions 2024 What medical term describes the surgical removal of the gallbladder? Cholecystectomy What does "PHI" stand for? Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. False A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? Craniotomy 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? Established 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? Yes What medical term would best describe "the likely course or outcome of a disease"? Prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have"? 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? Multiple complaints structure Which of the following is NOT a purpose of HITECH? 1. To require equal access, opportunity, and affordability for health insurance plans by screening patient health information 2. To require government accountability on health insurance plans available in the market place 3. To require encryption when using technology to transmit patient related information 4. 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? Hepatitis For correct billing and reimbursement to go through, a counseling note requires docuementation of the following: 1. Total time with the patient 2. 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? Chronologic Structure and Multiple complaints structure Which of the following would be valid complications for CAD? MI Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a NEW patient: 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 justifiable for you to use your EMR login to look up the important patient information. False What condition correctly describes "dangerous infection of the appendix"? Appendicitis An elderly male patient has a history of an enlarged prostate. What PMHx would you record into the chart? BPH-Benign Prostatic Hyperplasia A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic condition should be included in their diagnosis today? Coronary Artery Disease 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? Waxing and waning Which of the following would be included in a Problem List? Family hx of renal cancer Pyelonephritis, resolved Hx of renal stone extraction Nephrolithiasis, stable 1. Pyelonephritis, resolved Nephrolithiasis, stabl 2. What condition correctly describes "heart attack"? 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? Benign Prostate Hyperplasia- What medical term is used to describe the symptom of a patient's heart beating rapidly, irregularly, or forcibly? 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? 1. Diagnosis 2. Prognosis/Plan 3. Age and sex 4. PHx, if relevant 5. HPI 6. Results T/F. All symptoms documented in the ROS are also documented in the HPI. False What is the medical term for "open heart surgery"? 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. 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? 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"? CAD 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? Bone Fx Organize the parts of the chart in order from top (1) to bottom (7). 1. HPI 2. ROS 3. PMHx 4. PE 5. Orders/Results 6. Assessment 7. Plan What ROS system would include dysphagia, the medical term for difficult or painful swallowing? ENT T/F. The ROS does not contain the CC and its associated symptoms because they are already listed in the HPI. False T/F. Resolved problems may be deleted from the problem list. False A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? CABG What FHx/SHx information is usually asked for pediatric patients? Second hand smoke exposure Immunization status What is the medical term for "pass-out"? Syncope Which symptom(s) would a patient most likely present with if they had HLD? Asymptomatic T/F. Scribes should complete all charts by entering a scribe attestation before leaving the shift. 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? 1. Modifying factor 2. Relevant context 3. Severity A female patient underwent surgery to have her ovary removed. What PSHx would you record into the chart? Oophorectomy A patient comes into the clinic for a well woman exam. What type of clinic visit is this? Health management visit A patient has an E&M code of 99215. What information does this code give? LOS 5, Established patient Match the chronic condition with it's corresponding nonpharmacological treatment: DM Low carb diet, increase physical activity Match the chronic condition with it's corresponding nonpharmacological treatment: HTN Low sodium diet, decrease ETOH intake, increase physical activity Match the chronic condition with it's corresponding nonpharmacological treatment: HLD Low fat diet, increase physical activity T/F. One of your co-workers is having difficulty printing a CT report and asks you to look up the report for them. You can look up the report as long as you do not read it. False A female patient underwent surgery to have an ovary and fallopian tube removed. What PSHx would you record into the chart? Salpingectomy A modifier code usually gives information about which type of code? Procedure code What three details should be included in a sentence summarizing results in the Assessment Section? 1. Name of test 2. Reason for why the test was ordered 3. Result of test Which of the following details could be categorized as the HPI element context? 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? Dyspnea A patient comes into the clinic for 3 weeks of a productive cough. What type of clinic visit is this? Diagnostic visit Which two codes should always be included on every superbill? E&M code, ICD code Which of the following would be valid complications for HTN? CRF, Impaired vision, CAD, CHF, MI What condition correctly describes "A bacterial lung infection"? Pneumonia A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart? 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. False What is the medical term for difficulty breathing? Dyspnea What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"? Genitourinary What surgical procedure should be performed to diagnose CAD? Angioplasty