Medical Scribe — Proficiency Exam

15 questions · pass with 50%

1. During an exam the provider listens to the patient's chest but says nothing about the lungs. What should you put in the exam section?
Lungs clear to auscultation bilaterally, since that is the usual findingCopy the lung exam from the patient's last visit noteLeave it out and ask the provider what they heard before the note is signedWrite that the lung exam was deferred
2. A patient turns to you while the provider is out of the room and asks whether her cholesterol result is dangerous. What is the correct response?
Tell her you cannot discuss her results and that the provider will go over them with herRead the numbers out and let her decideExplain the reference range but avoid saying whether it is dangerousTell her it looks fine so she does not worry
3. Your cousin is admitted to the hospital where you scribe. You have chart access. What may you do?
Look at her chart because you are family and concernedLook but not tell anyone what you sawAsk a nurse to read the chart to you insteadNothing — you may not open the chart unless she is a patient in your provider's care
4. Which of these tasks is normally inside a scribe's scope?
Entering and releasing a prescription refill the provider mentionedPulling up a prior CT report because the provider asked to see itRepeating a blood pressure the nurse recorded earlierExplaining discharge instructions to the patient
5. You duplicate yesterday's progress note to save time. What is the most likely harm?
The note will be too short to billThe note will contain findings and problems that were not re-assessed todayThe EHR will lock the note for editingThe provider will have to re-enter the patient header
6. You insert a smart phrase that automatically pulls in the patient's vital signs. The nurse then corrects the blood pressure in the flowsheet. What is true of your note?
The note updates automatically because the field is linkedThe note will show both values side by sideThe provider must delete the whole note and start againThe note still shows the value as it was when you inserted it, unless you refresh it
7. A patient says she takes furosemide only on days her ankles look swollen. How should this be recorded?
Record the actual reported pattern of use rather than the prescribed daily scheduleRecord it as prescribed, since that is the official orderLeave the medication off the list because adherence is unclearRecord it as discontinued
8. Which allergy entry is most clinically useful?
Penicillin — allergyPenicillin — patient says noPenicillin — hives and lip swelling within an hour of first dosePenicillin — avoid
9. A patient says her headache is "like a band squeezing all the way around." Which HPI element does that phrase supply?
SeverityTimingContextQuality
10. The provider asks about cough, fever and shortness of breath only. Your template inserts a negative twelve-system ROS. What should you do?
Leave it — the template is the site standardCut it back to the systems actually reviewedKeep it but add a note that it was templatedDelete the ROS section entirely
11. Which past surgical history entry is documented correctly?
Knee surgery, a few years agoArthroplasty, rightRight total knee arthroplasty, 2019Total knee replacement, recent
12. The provider dictates a dose as "point five milligrams of a benzodiazepine." How do you write the number?
0.5 mg.5 mg0.50 mg1/2 mg
13. Mid-history you miss a medication name the patient rattles off. What is the correct action?
Write the closest drug name you can think ofDrop a placeholder, keep pace, and confirm it before the note is signedOmit the medication since it is already on the med listStop the encounter and ask the patient to repeat it
14. Your note template pre-populates a full normal neurological exam. The provider only checked strength and gait. What do you do?
Leave the template intact since nothing abnormal was foundAdd a comment that the rest was not indicatedDelete every element the provider did not perform, leaving strength and gaitReplace the section with the previous visit's neuro exam
15. Which laceration description is adequate documentation?
3 cm linear laceration to the left volar forearm, no visible foreign body, no tendon involvementSmall cut on the arm, cleaned and closedLaceration, sutured, patient tolerated wellForearm wound, moderate size

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