ScribeU Final Flashcards
select the 5 chart sections that should always be completed and reviewed prior to the patient being discharged?
vitals
exam
procedures
plan
diagnosis
which of the following findings would be documented under the abdominal section of the physical exam? (select all that apply)
ataxia
adnexal tenderness
splenomegaly
Rovsing’s sign
McBurney’s point tenderness
Homan’s Sign
Anatomical snuffbox tenderness
Valgus test
splenomegaly
McBurney’s point tenderness
Rovsing’s sign
The provider insists the patient should go to the ER for further evaluation, but the patient states they do not think it is necessary and chooses to go home. Which of the following MUST occur following this?
document the conversation between the provider and the patient
when do you select “intermediate” for complexity when documenting suture in the wound repair tab?
- never, this option is never used
- never, this is selected automatically based on the charting
never, this is selected automatically based on the charting
which of the following are appropriate orders for dexamethasone at TAUC? (select all that apply)
dex, oral, 4mg
dex, IM, 8mg
dex, IV, 4mg
The provider did not shine a light in the patient’s eyes during the exam. Which finding below is NOT appropriate to keep in the eye section of the physical exam?
PERRL
A patient was discharge with a tall walking boot and crutches. How are the crutches charted?
add a note to the splint/casts section
what is the standard dose of metoclopramide IVPB?
10 mg
which of the following body sections do we mostly free text when adding physical exam findings?
Skin, Hair, Nails
Musculoskeletal
Patients with damage to which organ should NOT receive Tylenol?
liver
select the diagnoses that cover for a flu test
influenza
viral syndrome
URI, NOS
fever
cough
influenza
viral syndrome
URI, NOS
cough
when charting an Abscess I&D, when do you elect I&D Abscess Mult/Comp instead of just I&D Abscess?
the abscess is packed
the provider notes breaking up “loculations”
what medication level severity do you inform the provider of before adding the medication to the patient’s plan?
always tell the provider
which bones do not have treat fracture codes?
ribs
scull
vertebrae
acromion
to look for corneal abrasions, what must the provider perform?
Fluorescein exam
what class of medication is used to treat shingles?
antiviral
You are reviewing a patient’s surgical history and see that they have a history of hysterectomy, cholecystectomy, appendectomy, tonsillectomy, and shoulder surgery. Select which of the following actions you would take:
remove the “tonsils” from the physical exam
if a patient had an IV, a ______ order must be added before discharge.
Vitals and IV D/C
in what body section would you document fluctuance and induration?
Skin, Hair, Nails
when ordering a CT on a female, what age range requires a UPT or a signed waiver?
14-59
what does it mean if a room number background is yellow and what do you do? (select the 3 that apply)
-the scribe should bubble the discharge once the physician has seen the patient after the APP
-the APP is done with the patient
-the patient is ready to be seen by the physician
You are receiving a CT/US transfer from another site. Select the following requires in the new chart?
-vitals
-a short HPI/note explaining the transfer from the initial location
-diagnosis/plan
-procedures
-vitals
-a short HPI/note explaining the transfer from the initial location
-diagnosis/plan
-procedures
You are working with a PA at a site that does not have a physician. They want to send a prescription to a pharmacy and tell you to be sure to include their SP when sending it. Select the best 2 options for accomplishing this.
-select the SP from the Coding tab, send the prescription, then remove the SP
-write the name of the SP in the notes section of the prescription
choose the following scenarios that require you to override billing when ordering a urine culture (or any Quest labs)
work comp/occ. health
self pay