AST V3 Lecture 6 Assessment

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  • 1/30 Questions

    The assessment and plan are determined by the... (Check all that apply.)

    • Provider
    • Medical Assistant
    • Scribe
    • Patient
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About This Quiz

The AST V3 Lecture 6 Assessment tests knowledge on medical scribing, focusing on tasks like organizing plan details and understanding provider-determined assessments. It enhances skills in accurate medical documentation, crucial for effective healthcare administration.

AST V3 Lecture 6 Assessment - Quiz

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  • 2. 

    It is your job as a scribe to decide which diagnosis should be inputted for the patient.

    • True

    • False

    Correct Answer
    A. False
    Explanation
    As a scribe, it is not the job to decide the diagnosis for the patient. The role of a scribe is to accurately document the physician's observations, diagnoses, and treatments. The decision of the diagnosis is the responsibility of the physician based on their expertise and evaluation of the patient's symptoms and medical history. Therefore, the statement is false.

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  • 3. 

    It is your job as a scribe to organize and rephrase the plan details into standard medical phrasing.

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The statement suggests that as a scribe, it is the job of the individual to take the plan details and rephrase them using standard medical language. This implies that organizing and using proper medical terminology is a crucial part of the scribe's role. Therefore, the correct answer is True.

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  • 4. 

    Which lab order contains the following lab tests: WBC, Hgb, HCT, Platelets, RBC

    • Complete Blood Count (CBC)

    • Basic Metabolic Panel (BMP)

    • Liver Panel

    • AST/ALT

    Correct Answer
    A. Complete Blood Count (CBC)
    Explanation
    The lab order that contains the lab tests WBC, Hgb, HCT, Platelets, and RBC is the Complete Blood Count (CBC). The CBC is a common blood test that provides information about the different types and numbers of cells in the blood, including white blood cells (WBC), red blood cells (RBC), hemoglobin (Hgb), hematocrit (HCT), and platelets. It is often used to evaluate overall health, screen for various conditions, and monitor the effectiveness of treatments.

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  • 5. 

    Any diagnosis/impression included in the A/P must be absolute and definite.

    • True

    • False

    Correct Answer
    A. False
    Explanation
    The statement is false because a diagnosis/impression included in the A/P (Assessment/Plan) does not have to be absolute and definite. In medical practice, sometimes there may be uncertainty or the need for further testing before a definitive diagnosis can be made. Therefore, a diagnosis or impression included in the A/P can be provisional or tentative, indicating that it is subject to further evaluation or confirmation.

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  • 6. 

    According to Augmedix's standard Assessment/Plan Style, how should assessments be organized?

    • Listed in order of most to least significant

    • Listed in the order they are dictated by the provider

    • Listed in the order of most to least instructions

    • Listed in the order discussed with the patient

    Correct Answer
    A. Listed in order of most to least significant
    Explanation
    Assessments should be organized according to Augmedix's standard Assessment/Plan Style by listing them in order of most to least significant. This means that the most important assessments should be listed first, followed by the less significant ones. This organization helps prioritize the assessments and ensures that the most critical information is easily accessible and highlighted.

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  • 7. 

    Patient: I have this weird rash on my right thigh.Provider: Let me take a look. HmmPatient: Yeah, I don't really know what to make of it. It just appeared a few days ago.Provider: Hm okay, there's a great derm clinic down the street, I will defer to them on this one.Patient: Okay, can I just walk in there?Provider: No, I can call ahead and let them know to expect a call from you to make an appointment with one of their specialists.Patient: Okay any timeline I should expect? I feel like it might be getting worse.Provider: If you notice your symptoms worsening, give my nurse a call and we will get you in.Patient: Cool, thanks.What assessment should the scribe input based on the conversation above?

    • Rash

    • Skin Symptoms

    • Psoriasis

    • None of these options.

    Correct Answer
    A. None of these options.
    Explanation
    No assessment is clear based on this conversation. Therefore, no assessment should be inputted by the scribe until the provider has clarified.

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  • 8. 

    Patient: I have this weird rash on my right thigh.Provider: Let me take a look. HmmPatient: Yeah, I don't really know what to make of it. It just appeared a few days ago.Provider: Hm okay, there's a great derm clinic down the street, I will defer to them on this one.Patient: Okay, can I just walk in there?Provider: No, I can call ahead and let them know to expect a call from you to make an appointment with Dr. Hansen.Patient: Okay any timeline I should expect? I feel like it might be getting worse.Provider: If you notice your symptoms worsening, give my nurse a call and we will get you in.Patient: Cool, thanks.Which of the following standard phrases would you use to document the plan information contained in this dialogue? (Check all that apply.)

    • Follow up in [TIME]

    • Call office if symptoms persist/worsen

    • Keep appointment with [SPECIALTY] as scheduled

    • Schedule an appointment with [NAME], [SPECIALTY]

    • Advised the patient to avoid [ACTION]

    Correct Answer(s)
    A. Call office if symptoms persist/worsen
    A. Schedule an appointment with [NAME], [SPECIALTY]
    Explanation
    The provider advised the patient to call the office if symptoms persist or worsen, and to schedule an appointment with Dr. Hansen, a specialist, to address the rash on the patient's right thigh.

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  • 9. 

    What is the definition of a differential diagnosis?

    • A group of diagnoses that are all true.

    • 2+ diagnoses that share similar signs/symptoms. The diagnosis may be uncertain.

    • One definite diagnosis.

    • A diagnosis that has been ruled out.

    Correct Answer
    A. 2+ diagnoses that share similar signs/symptoms. The diagnosis may be uncertain.
    Explanation
    A differential diagnosis refers to a group of diagnoses that share similar signs and symptoms. This means that there are multiple possible diagnoses that could explain the patient's symptoms, and it is uncertain which one is the correct diagnosis. The healthcare provider must consider all the possibilities and gather more information to make a final diagnosis.

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  • 10. 

    Provider: "You should really do your best to stop smoking. It'll kill you!"What is the BEST way to write the above quote in the plan?

    • Smoking cessation advised.

    • I have advised the patient to stop smoking because it may kill them.

    • I told the patient, "You should really do your best to stop smoking. It'll kill you!"

    • I advised the patient to do their best to stop smoking.

    Correct Answer
    A. Smoking cessation advised.
    Explanation
    The correct answer is "Smoking cessation advised" because it is a concise and professional way to convey the message of advising the patient to stop smoking. It captures the essence of the provider's statement without any additional information or direct quotes.

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  • 11. 

    New rx for Ativan 1mg prn, when anxiousWhich of the following phrases is the BEST option for the above information?

    • Prescribed [MEDICATION] [DOSAGE] for [CONDITION].

    • Refilled [MEDICATION].

    • Tolerating treatment of [CONDITION] with [MEDICATION].

    • … is treating his/her [CONDITION] with [MEDICATION]

    Correct Answer
    A. Prescribed [MEDICATION] [DOSAGE] for [CONDITION].
    Explanation
    Prescribed Ativan 1mg prn for anxiety.

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  • 12. 

    Provider: "No lifting objects over 50lbs for the next 2 months."Which of the following phrases is the BEST option for the above information?

    • Advised the patient to avoid [ACTION]

    • Precautions given for [MEDICATION] to avoid [ACTIVITY/SUBSTANCE]

    • … symptoms are aggravated/alleviated by [FACTOR]

    • ... complains of [COMPLAINT], worse/better with [FACTOR]

    Correct Answer
    A. Advised the patient to avoid [ACTION]
  • 13. 

    How are providers reimbursed for the care they provide?

    • ICD-10 codes

    • Patient's medical history

    • How well the patient responds to treatment

    • The patient pays based on the quality of care.

    Correct Answer
    A. ICD-10 codes
    Explanation
    Providers are reimbursed for the care they provide based on ICD-10 codes. These codes are used to classify and report diagnoses, symptoms, and procedures, allowing healthcare providers to accurately document and bill for their services. Reimbursement is typically determined by insurance companies and government payers who review the ICD-10 codes submitted by providers to determine the appropriate payment for the care provided.

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  • 14. 

    It is your responsibility as a scribe to know ICD-10 codes for common diagnoses.

    • True

    • False

    Correct Answer
    A. False
    Explanation
    As a scribe, it is not your responsibility to know ICD-10 codes for common diagnoses. Your role is to assist healthcare professionals by documenting patient encounters accurately and efficiently. While having knowledge of common diagnoses and medical terminology is beneficial, it is not a requirement for the position. The responsibility of assigning ICD-10 codes typically falls on medical coders or billing specialists who have specialized training in coding and reimbursement.

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  • 15. 

    Which of the following is the LEAST medically relevant plan detail.

    • Potential side effects of atorvastatin were discussed in detail.

    • Apply warm compresses every 3 hours.

    • Maintain a healthy diet and avoid dairy.

    • Encouraged to run at a medium pace, at night to avoid overheating. Eat no wheat prior to exercise. Eat a protein rich meal after exercise.

    Correct Answer
    A. Encouraged to run at a medium pace, at night to avoid overheating. Eat no wheat prior to exercise. Eat a protein rich meal after exercise.
    Explanation
    The other plan details mentioned in the options are all related to medical concerns and instructions, such as discussing potential side effects of a medication, applying warm compresses, and maintaining a healthy diet. However, the last option about running at a medium pace at night and avoiding wheat prior to exercise does not directly pertain to a medical condition or treatment. It seems to be more focused on personal fitness and dietary preferences rather than a medically relevant plan detail.

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  • 16. 

    When the provider said, "I'm going to write a script for PT formally over to Ed in the department," what does he mean by "PT"?

    • Part time work

    • Physical therapy

    • Percutaneous surgery

    • Prothrombin time, a measure of blood coagulation

    Correct Answer
    A. Physical therapy
    Explanation
    The provider is referring to "PT" as an abbreviation for "Physical therapy." In this context, the provider is stating that they will be writing a script or referral for a patient to receive physical therapy services from Ed in the department.

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  • 17. 

    Which of the following is LEAST likely to be an Assessment?

    • Lipoma

    • Back pain

    • Scoliosis

    • Shoulder injury

    Correct Answer
    A. Shoulder injury
    Explanation
    The given options consist of medical conditions, and the question asks for the least likely assessment. Assessments typically involve evaluating or diagnosing a condition or injury. Lipoma, back pain, and scoliosis are all medical conditions that could be assessed. However, a shoulder injury is more likely to be assessed rather than being an assessment itself. Therefore, the least likely assessment among the given options is a shoulder injury.

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  • 18. 

    When the provider said, "Ok, they will be downstairs waiting in radiology for you," this is a clue that...

    • The provider ordered an imaging study that will be done now

    • The patient has another scheduled appointment with a radiologist

    • The receptionist is in the radiologist's office

    • The radiologist has asked to see the patient for another concerning imaging impression

    Correct Answer
    A. The provider ordered an imaging study that will be done now
    Explanation
    The provider's statement indicates that the patient will be waiting in radiology, suggesting that an imaging study has been ordered and will be conducted immediately.

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  • 19. 

    How should this A/P be written?

    • As a list.

    • In paragraph form.

    • In shorthand notation.

    • Depends on the provider's preferences.

    Correct Answer
    A. Depends on the provider's preferences.
    Explanation
    The way this A/P should be written depends on the preferences of the provider. Different providers may have different preferences for formatting and organization. Some may prefer a list format, while others may prefer paragraph form or shorthand notation. Therefore, the correct answer is that it depends on the provider's preferences.

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  • 20. 

    Based on the dialogue, which of the following should be included in the Plan?

    • The patient should follow up with a surgeon to schedule lipoma excision surgery.

    • Patient is referred to physical therapy.

    • Continue current diet regimen.

    • Ordered thoracolumbar series.

    Correct Answer(s)
    A. Patient is referred to physical therapy.
    A. Ordered thoracolumbar series.
    Explanation
    The dialogue suggests that the patient should be referred to physical therapy, indicating that it is an important component of the plan. Additionally, the dialogue mentions that an order was placed for a thoracolumbar series, indicating that it should also be included in the plan. The other options, scheduling lipoma excision surgery and continuing the current diet regimen, are not mentioned in the dialogue and therefore should not be included in the plan.

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  • 21. 

    Based on this dialogue, the scribe should ask which assessments to input into the EHR.

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The dialogue mentioned in the question implies that there is a need to input certain assessments into the EHR. Therefore, it is logical for the scribe to ask which assessments should be inputted. Hence, the correct answer is "True".

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  • 22. 

    Which of the following were discussed during this visit? (Check all that apply.)

    • Back pain

    • Mass of fat over shoulder blade

    • Bone density screening

    • Osteopenia risk factors

    • Recent back injury

    • Prescription for pain medication

    Correct Answer(s)
    A. Back pain
    A. Mass of fat over shoulder blade
    A. Bone density screening
    A. Osteopenia risk factors
    Explanation
    During the visit, the following topics were discussed: back pain, mass of fat over the shoulder blade, bone density screening, and osteopenia risk factors.

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  • 23. 

    Based on the dialogue, which of the following Plan details were discussed? (Check all that apply.)HINT: A discussion means that plan options were discussed, NOT that the plan was advised or ordered.

    • Referrals

    • Medication

    • Surgical intervention

    • Imaging

    Correct Answer(s)
    A. Referrals
    A. Surgical intervention
    A. Imaging
    Explanation
    The dialogue mentioned a discussion about plan details, which implies that different options were considered or talked about. Referrals, surgical intervention, and imaging were specifically mentioned as topics of discussion. However, there is no mention of medication being discussed, so it is not one of the plan details that were discussed.

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  • 24. 

    Patient: I have this weird rash on my right thigh.Provider: Let me take a look. HmmPatient: Yeah, I don't really know what to make of it. It just appeared a few days ago.Provider: Hm okay, there's a great derm clinic down the street, I will defer to them on this one.Patient: Okay, can I just walk in there?Provider: No, I can call ahead and let them know to expect a call from you to make an appointment with one of their specialists.Patient: Okay any timeline I should expect? I feel like it might be getting worse.Provider: If you notice your symptoms worsening, give my nurse a call and we will get you in.Patient: Cool, thanks.Based on the above dialogue what information are you given? (Check all that apply.)

    • Onset/Duration

    • Complaint

    • Assessment

    • Exam findings

    • Plan

    • Location

    • Timing

    Correct Answer(s)
    A. Onset/Duration
    A. Complaint
    A. Plan
    A. Location
    A. Timing
    Explanation
    The dialogue provides information about the onset/duration of the rash (appeared a few days ago), the patient's complaint (weird rash on right thigh), the provider's plan (referring to a dermatology clinic and suggesting making an appointment), the location of the rash (right thigh), and the timing of seeking medical attention (if symptoms worsen). The dialogue does not provide any information about assessment or exam findings.

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  • 25. 

    Which of the following might the provider want included in the A/P? (Check all that apply.)

    • Imaging results

    • Lipoma exam findings

    • Absence of physical symptoms related to lipoma

    • Scoliosis

    Correct Answer(s)
    A. Imaging results
    A. Lipoma exam findings
    A. Absence of physical symptoms related to lipoma
    A. Scoliosis
    Explanation
    The provider would want the imaging results to assess the lipoma and determine any potential complications or treatment options. The lipoma exam findings would provide further information about the size, location, and characteristics of the lipoma. The absence of physical symptoms related to the lipoma would indicate that it is not causing any discomfort or complications. Scoliosis may or may not be related to the lipoma, but it is important to include in the A/P as it is a separate condition that needs to be addressed.

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  • 26. 

    The A/P can include which of the following? (Check all that apply.)

    • Procedure

    • Referral

    • Follow up instructions

    • Subjective information

    • Objective information

    • Imaging impressions

    Correct Answer(s)
    A. Procedure
    A. Referral
    A. Follow up instructions
    A. Subjective information
    A. Objective information
    A. Imaging impressions
    Explanation
    The A/P can be a combination of all information from the note. If the provider wants to include his/her medical reasoning based on subjective information, objective information, imaging impressions, all of that can be included in the A/P.

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  • 27. 

    Where might an imaging impression be recorded or discussed?

    • HPI

    • PE

    • Past Medical History

    • A/P

    Correct Answer(s)
    A. HPI
    A. PE
    A. A/P
    Explanation
    An imaging impression is likely to be recorded or discussed in the HPI (History of Present Illness), PE (Physical Examination), and A/P (Assessment and Plan) sections. The HPI allows the healthcare provider to gather information about the patient's symptoms and medical history, including any relevant imaging studies. The PE involves a physical examination, which may include the interpretation of imaging findings. Finally, the A/P section summarizes the provider's assessment of the patient's condition, including any imaging impressions and the plan for further evaluation or treatment.

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  • 28. 

    This audio recording is based on a real patient visit. Take notes on the information you think is relevant from the visit.This audio recording applies to question 21-30.

  • 29. 

    Take your notes below.

Quiz Review Timeline (Updated): Jul 28, 2023 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Jul 28, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jun 27, 2016
    Quiz Created by
    Firstsourcetrain

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