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
if a patient has an abrasion to the right cheek, then which of the following normal finding(s) should ALWAYS be unchecked? (select all that apply)
atraumatic
the use of dexamethasone is contraindicated if the patient has which condition in their past medical history?
diabetes
what order must be select for every patient?
patient ready to discharge
Which of the following are medical CTs? (select all that apply)
CT Abd Pelvis w/ IV Contrast
CT Abd Pelvis w/o IV Contrast
CT Angio Chest w/ IV Contrast
CT Brain w/o IV Contrast
CT Chest (thorax) w/ IV Contrast
CT Facial/Sinuses Complete w/o IV Contrast
CT Neck w/ IV Contrast
CT C-Spine w/o IV Contrast
CT Abd Pelvis w/ IV Contrast
CT Abd Pelvis w/o IV Contrast
CT Neck w/ IV Contrast
CT Brain w/o IV Contrast
You are working at TAUC 3 and one of your patients needs an ultrasound for the next day. What 3 steps do you follow?
-select an available appointment time and fill out the text boxes with the patient’s PID, email, US type, and your name
-click in the link above the calendar to open the ultrasound appointment time slots
-log onto TeamTAUC.com and click on “Ultrasound”
-view the ultrasound calendar on the TAUC drive to see if an US tech is available
-select an available appointment time and fill out the text boxes with the patient’s PID, email, US type, and your name
-click in the link above the calendar to open the ultrasound appointment time slots
-log onto TeamTAUC.com and click on “Ultrasound”
Patient comes in for a dog bite to the right hand that occurred 1 hour ago and the provider prescribes Augmentin BID x 10 days. Which of the following options would be an appropriate primary diagnosis?
-laceration w/o foreign body of right hand, initial encounter
-puncture wound w/o foreign body of right hand, initial encounter
-bitten by dog, initial encounter
-laceration w/o foreign body of right hand, initial encounter
-puncture wound w/o foreign body of right hand, initial encounter
which of the following would be dosucmented under the Musculoskeletal section of the Physical Exam? (select all that apply)
-midline bony tenderness
-anatomical snuffbox tenderness
-Valgus Test
-Homan’s Sign
-midline bony tenderness
-anatomical snuffbox tenderness
-Valgus Test
-Homan’s Sign
The Uric Acid Panel (Chem-13) also contains everything included in the _____, plus some more tests.
Liver Function Panel
When is it acceptable to select the “reviewed” for a particular tab in a patient’s chart?
if all the past medical history is complete and checked
A patient presents to TAUC with a copy of lab work performed by their PCP. Which of the following is an acceptable way to document this?
-there is no need for any additional documentation
-a procedure note stating what tests were done, by whom, and what the results show
a procedure note stating what tests were done, by whom, and what the results show
(T/F): The provider recommends the patient et an MRI. This recommendation should be included in the chart.
True
Which of the following diagnoses are not allowed to be a primary diagnosis in the patient’s chart?
-Bitten by Dog, Initial Encounter
-COVID-19, suspected exposure
-Fall, Initial Encounter
-MVC, Driver
-Bitten by Dog, Initial Encounter
-Fall, Initial Encounter
-MVC, Driver
Select the “4 Normals” for an EKG
NL ST-T
NL intervals
NL axis
NSR
(T/F): If a provider has not specified their preferred dose of dexamethasone, you should always order 4mg.
False
A patient presents to the clnic for a laceration which happened 2 days ago. Because it happened such a long time ago, the provider does not suture the wound. Which are acceptable ways to document this in the chart?
-Selecting “wound not repaired” under wound repair and selecting “delay in seeking care”
-Writing a procedure note describing the delay in seeking care and stating why the wound was not repaired
in which of the following situations would you NOT need to document a discussion regarding a medication?
-the provider tells the patient to take a smaller does of a previously prescribed medication
-the patinet is advised to discontinue a chronic medication
-a patient refused a prescription medication
-the patient is started on a new medication for the first time through TAUC
-the patient is advised to continue a previously prescribed medication
the patient is started on a new medication for the first time through TAUC
What are the 2 most important areas of the chart to document throughly to justify ordering any CT?
HPI
Physical Exam
Which of the following findings would be documented under the Skin, Hair, Nails section of the Physical Exam? (select all that apply)
-erythema
-septal hematoma
-petechiae
-lymphangitis
-erythema
-petechiae
-lymphangitis
Where can you find the BP recheck order?
Main Tab
In what body section would you document maxillary sinus tenderness?
Head
Your provider consults with an outside specialist about a patient you are seeing. How should you include this in the chart?
A procedure note saying who was spoken to as well as their recommendation
A patient is sent to the ER via EMS for chest pain from TAUC 1. During their visit at TAUC 1 the patient had a workup including an EKG, CBC, I-STAT, Cardiac Panel, Chest x-ray, and CT PE study. Select all items that should be ordered for the patient.
-Disc w/ all radiology studies (DISC)
-Print radiology report (RAD)
-Print clinical summary (ER)
-Print demographics sheet
-EKG (confirmed scanned) to packet (EKG)
-IV option: Vitals and leave saline lock
-Disc w/ all radiology studies (DISC)
-Print radiology report (RAD)
-Print clinical summary (ER)
-EKG (confirmed scanned) to packet (EKG)
-IV option: Vitals and leave saline lock
A patient was in an MVC and reports to TAUC1. She complains of hitting her head against the dashboard, pain over left cheek, neck pain, a bruise on the anterior chest from the seat belt, and right abdomen pain. She receives 5 trauma CT scans. Fortunately, each CT scan comes back unremarkable. Select each diagnosis that will cover the CT scans.
-cervical strain
-closed head injury
-abdominal contusion
-facial contusion
-chest contusion
15 y/o M c/o 3 days of fever (up to 102F at home) with chills, sore throat, and reports his “muscles feel weird”. The ,mother reports that a letter came home from school, and there is a mono outbreak. Pt also reports decreased appetite. The tech has already ordered 4mg dex, and flu and strep tests. The provider orders a mono test. While waiting for the mono test result, what diagnosis should be considered to cover for the tests ordered?
-viral syndrome
-pain in throat
(T/F): If the provider asks the patient pertinent negative questions, these should be documented in the HPI.
true
Select the 3 places of plan advice that we give to nearly every patient.
Fluids
Rest
RTC if s/s change
If a patient is diagnosed with a fracture, what additional order must always be selected (excluding the exceptions)?
treat fracture code
A patient received an IV during their visit. What is the minimum number of times their vitals should be checked during the visit?
2
45 y/o F presents with RUQ abdominal pain. Upon exam, the provider decides to order a CT Abd/Pelvis with contrast. What additional orders MUST be put in?
-UPT
-Metlyte Panel (Basic Met w/ CK)
-IV/blood collection
which of the following finding(s) would be documented under the GU/Rectal section of the physical exam? (select all that apply)
hypoperistalsis
adnexal tenderness
malodorous white discharge
testicular swelling
anal fissure
adnexal tenderness
malodorous white discharge
testicular swelling
anal fissure
Your provider gives a Skin, Hair, and Nails exam as follows: “2 x 6cm maculopapular area of erythema and warmth notes to the left anterior thigh, mild TTP. No blanching, edema, or vesicular lesions noted.” What must be removed from the imported exam template?
-normal skin temperature
-no rashes
-normal skin to palpation
-normal skin temperature
-normal skin to palpation
(T/F) a patient is currently taking a medication that causes unwanted side effects. the provider tells the patient to continue the medication, but to only take half a pill at each does instead of a full pill. this discussion must be documented in the chart
True
A patient has positive CVA tenderness on exam. Which condition might we be concerned for?
Pyelonephritis
What is the standard single does strength for Toradol IV vs IM at TAUC?
15mg IV vs 15mg IM
30mg IV vs 15mg IM
15mg IV vs 30mg IM
30mg IV vs 30mg IM
15mg IV vs 30mg IM
You are at TAUC 15 and sending a patient to TAUC 1 for a CT scan. What steps must you take?
-Call TAUC 1 front desk and let them know the patient will be arriving at TAUC 1 for a CT scan
-Call Rad Questions (x7950) to discuss the desired scans(s)
-Fill out the CT Transfer sheet with orders for the receiving site
-Contact CT tech to discuss scan desired
-If CT does not answer, call TAUC 1 TL, inform them of transfer, and ask them to have CT return your call.
-Call Rad Questions (x7950) to discuss the desired scans(s)
-Fill out the CT Transfer sheet with orders for the receiving site
In what body section do you document boggy mucosa?
Nose
which of the following situations always requires that a note be added to a patient’s chart?
-the patient does not have a PCP
-the patient is sent to the ER
-the patient declines IV fluids and blood work
-the patient has a history of hypertension and has a normal BP while at TAUC
-the patient is unable to give an accurate history, so an independent historian is needed
-the patient declines a CT scan
-the patient is told to stop a prescription medication
-the patient is blind and is brought in by their spouse
-the patient declines a prescription medication
-the patient sees a specialist for a problem unrelated to their TAUC visit
-the patient is started on a new medication through TAUC
-the patient declines a prescription medication
-the patient is told to stop a prescription medication
-the patient declines a CT scan
the patient declines IV fluids and blood work
-the patient is sent to the ER
-the patient is unable to give an accurate history, so an independent historian is needed
You hear the provider saw the word “infiltrate” as a part of a CXR reading. What is the diagnosis?
pneumonia
which of the following findings(s) would be documented under the ear section of the physical exam? (select all that apply)
TM dullness
septal hematoma
Ceruminosis
pale conjuctiva
Foreign body to external canal
TM dullness
Ceruminosis
Foreign body to external canal
What do you have to order of the provider irrigates both of a patient’s ears, and the quanity does not automatically change to 2?
Ear Wax Removal (unilateral)
A patient presents with RLQ abdominal pain. On exam, patient has positive Poas sign, Roving’s Sign, McBurney’s Point Tenderness, and Heel Strike Test. What are you concerned for?
appendicitis
In what section are you documenting coughing?
general
(T/F): You are working at TAUC 1 during a time when we have a US tech present, and the provider would like to order an US. After communicating with with US tech present, you may order the US as you would a CT.
True
A patient presents with acute anaphylaxis. Which strength of epinephrine do you order for them?
1:1,000
What class of medication is given for tinea capitis?
-antibiotic
-antifungal
-muscle relaxer
-steroid
antifungal
A provider instructs a patient to not drink any alcohol while on a medication. Which are acceptable ways to include this information in the chart.
-A procedure note saying “instructed patient to not drink while on X medication. Patient agrees.”
-Putting the same warning in the patient’s plan.
Patient presents with an area of erythema to the right forearm with 2 central puncture wounds which are likely due to a spider bite. The area is warm and very tender to the touch. What medication will likely be given?
antibiotic
Which schedule does a self pay physical + 10 panel drug screen go on?
physical
18 y/o male self pay patient presents with a physical to play sports in school. What physical should you order?
Adult Physical (adult)
in which of the following causes would you need to document that a patient’s history is relayed by an independent historian?
-the patient speaks another language and has a translator
-the patient is deaf and uses a phone app to communicate
-the patient is a baby and accompanied by a parent
-the patient is an otherwise healthy adult accompanied by their spouse for comfort
the patient is a baby and accompanied by a parent
When documenting a provider performed procedure, do you click the “risks and benefits were explained…..” box under the procedure being performed?
yes
what body section do you document no CVA tenderness?
abdominal
where can you find the EKG w/ interpret order?
main tab
You are at TAUC 22 and the provider wants to order a CBC for the patient. Are you able to perform this lab test here?
no (TAUC 1 only)
Normal BP for a 30 y/o female.
118/78
A patient presents with SOB and was recently on a plane ride. The provider was distracted during the history by someone needing a medication initialed and may not have heard about the recent plane flight. What diagnosis are you worried (and may need to gently inform the provider regarding)?
pneumonia
pneumothorax
pulmonary embolism
pulmonary embolism
You are attempting to dispense a med, but the box under the “D” heading is not present. You have confirmed that we carry the medication and that the strength and total quantity are correct. What is the best NEXT step given these options?
-Manually dispense the medication
-Click the search tool above the medication list in the Plan and look for a version of the medication with the blue pill bottle icon next to it.
Click the search tool above the medication list in the Plan and look for a version of the medication with the blue pill bottle icon next to it.
You are the scribe at a site where the CT machine has gone down. The provider transfers the patient to another site for a CT abdomen/pelvis w/. In which chart do you input discharge orders?
the x-ray chart at the receiving site
What are the 3 things that must be included in the plan for all work comp patients? (select the 2 correct answers)
Met MMI, See RTW, Spoke to patient employer, Bob
-patient return to clinic on 4/21/24, spoke to patient employer, Bob, See RTW
What must be checked for any patient prior to receiving IV contrast?
creatinine level (via MetLyte)
What must already be documented in the patient’s chart prior to launching Lab interface?
diagnosis
Which of the following are trauma CTs? (select all that apply)
CT Abd Pelvis w/ IV Contrast
CT Abd Pelvis w/o IV Contrast
CT Angio Chest w/ IV Contrast
CT Brain w/o IV Contrast
CT Chest w/wo
CT Chest (thorax) w/ IV Contrast
CT Facial/Sinuses Complete w/o IV Contrast
CT Neck w/ IV Contrast
CT C-Spine w/o IV Contrast
CT Abd Pelvis w/ IV Contrast
CT Brain w/o IV Contrast
CT Chest (thorax) w/ IV Contrast
CT Facial/Sinuses Complete w/o IV Contrast
CT C-Spine w/o IV Contrast
You are at TAUC 1 and the provider requests a Comprehensive Metabolic Panel. What orders do you select?
-iSTAT Basic Met Panel
-CBC w/ DIff
-Liver Function Panel
-iSTAT Basic Met Panel
-Liver Function Panel
What is the login and password for AVRTeleris?
Username: tauc.reports
Password: taucis#1
how do you order a bilateral x-ray?
never, you order a separate left and right x-ray
The provider is sending a patient to the ER. Which of the following information should be included in the patient’s chart?
-how the patient is going to the ER (POV or EMS)
-which ER the patient is going to
-who the provider spoke to at the ER
-additional information the provider discussed with the patient prior to them leaving TAUC.
Where can you find the US coverage schedule?
Team TAUC
In what body section would you document carotid bruit?
neck
what are the best places to easily find the Quest Quick Guide to order common Lab Interface tests?
-TAUC drive- Lab folder
-TeamTAUC- provider references
-Quest website
-TAUC drive- Lab folder
-TeamTAUC- provider references
Which of the following finding(s) would be documented under the Chest/Lungs section of the physical exam? (select all that apply)
decreased breath sounds
guarding
retractions
tachycardia
costochondral tenderness
accessory muscle use
retractions
decreased breath sounds
accessory muscle use
costochondral tenderness
What is the standard does for Pepcid IVPB?
20mg
X-ray readings should always be entered in ___ by the provider.
OnePACS
A patient presents with an outside order for lab work, an EKG, and a chest x-ray from another PCP. Which schedule should the patient be placed on?
Med/Lab
Physical
Provider
provider
Select the abnormal RR and HR (respectively) for a 2 year old.
28, 120
16, 75
16, 75
Diagnoses with which word or words should be avoided in a patient’s Diagnosis/Plan, unless no other options available?
unspecified
You have a patient with no PMH of hypertension but we have recored a high BP while at TAUC. Select the diagnosis that you add and name the “scribe” instruction that should be added to the plan.
Elevated Blood Pressure w/o Diagnosis of Hypertension dx + Scribe BP Advice
