Which of the following are common general family Which of the following are tasks you ​can​ complete as

histories that physicians frequently ask about? a scribe?

A. DM A. Help a patient from his wheelchair to the
B. HTN exam chair
C. CA B. Locate previous results to show the provider
D. All the above C. Document history and physical exam while
the physician performs them
A chart for an established patient will be ___ D. Sign the doctor’s charts at the end of the day
A. More concise
B. Less concise In a diagnostic visit, the patient has a ____ complaint.
A. New
Name and correctly spell the following surgery: B. Existing
A. Heart bypass
B. Breast removal Who typically obtains quality measures like vital
C. Gallbladder removal signs during patient check-ins?
D. Uterus removal A. Scribe
E. Neck artery cleaned B. Physician
C. Nurse/Medical Assistant
Define the following terms: D. Registration
Subjective
Baseline The History and Physical (H&PD) is part of the ______
Outpatient evaluation.
Auscultation A. Nurse
Chief Complaint B. Provider

For each, what is the term that you would enter into
the chart for the following statements:
A. “My doctor says my heart is failing”
B. “I have high blood pressure”
C. I take shots for diabetes”
D. “I had a mini-stroke last year”
E. “I have acid reflux”
F. “I am not pregnant. I have two children, but I
miscarried my first pregnancy”
Label the following as subjective or objective:
Review of Systems
A) Subjective - Details of the chief complaint
History of present illness
B) Objective - Doctor’s assessment
Physical Exam
C) Subjective - Head to toe overview of symptoms
Which of the following are examples of mid-level
providers? (multiple answers)
A. NP
B. PA
C. EP
D. GYN
E. RN
Which of the following items would be included in the
patient’s plan (multiple answers):
A. Follow-up with a specialist
B. None of the above
C. Follow-up for the next routine appointment
D. Instructions for lifestyle and preventative
care
If a doctor tells you, “The lungs are clear”, where
would you document this?
A. Assessment
B. Review of Systems
C. History of present illness
D. Physical exam
The patient explains that he was on a smoking break
at work when he began to experience chest pain.
Which of the following items could you include in his
social history? (Multiple answers)
A. Smoking
B. Divorced
C. Employed
D. Occasional ETOH
E. Lives with family
Which of the following are examples of living
circumstances? (multiple answers)
A. Homeless/Shelter
B. Retired
C. Lives with family/friends
D. Employed as a teacher
E. Lives alone
F. Retired
G. Hospice
H. Nursing Home/ Assisted Living
Define the following terms:
Intermittent
Objective
Review of Systems
Exacerbate
Waxing and waning
Match the section title to the corresponding section
content:
Assessment
A) Chief complaint, HPI, ROS
Objective
B) Treatment, Follow-up plan for each diagnosis
Subjective
C) Diagnosis, Progress since last visit
Plan
D) Vital signs, physical exam, orders, results
Finish the sentence for questions your provider will
ask a patient who has had similar symptoms in the
past
A. Was there any ____ from previous evaluation?
B. Is there anything ____ about your symptoms
today?
C. Did you seek ___ at the time?
D. ___ did the symptoms occur?
(​New or different / Professional treatment / Result or
diagnosis / How long ago)
Identify the HPI elements in the following paragraph”
Jane Doe is a 35 y/o female presenting to the clinic
with abdominal pain for the past two days. She
describes the pain as intermittent cramping, located in
her RUQ. The pain became worse after a breakfast of
ham and eggs this morning and unchanged by Pepto
Bismol this afternoon. She notes nausea and a
subjective fever but denies any diarrhea dysuria,
backpain, CP or SOB. Otherwise, she has been in her
normal state of health and denies any new or different
complains.
A. Onset
B. Timing
C. Quality
D. Modifying factors
E. Associated symptoms/ Pertinent negatives
F. Location
G. Context
Which of the following are NOT elements of the HPI:
A. Location
B. Onset
C. Quality
D. Chief Complaint
E. Severity
F. Associated symptoms
True or False: Every billing level requires a chief
complaint in order to be reimbursed for services.
Which of the following CCs are NOT reimbursable?
(multiple answers)
A. Diabetes maintenance visit
B. Check-up
C. HTN management
D. Lab results
E. Follow-up visit
True/False: The review of systems is the story of the
symptoms and events that led to the clinic visit.
True/False: The entire clinic visit is based on the HPI
given by the patient.
True/False: It is okay to have a subjective complaint
in the HPI that isn’t followed up somewhere else.
What is the structure of the HPI in the paragraph
below?
Jane Doe is a 35 y/o female presenting to the clinic
with abdominal pain for the past two days. She
describes the pain as intermittent cramping, located in
her RUQ. The pain became worse after a breakfast of
ham and eggs this morning and unchanged by Pepto
Bismol this afternoon. She notes nausea and a
subjective fever but denies any diarrhea dysuria,
backpain, CP or SOB. Otherwise, she has been in her
normal state of health and denies any new or different
complains.
 A. Multiple complaint formula following symptoms will a patient with severe HTN
B. Single complaint formula will NOT experience?
C. Chronologic A. Epistaxis
B. HA
True/False: Information in the ROS can contradict in C. Blurred Vision
the HPI because the ROS is objective. D. Palpitations/CP
E. Leg rash
Y/N: Does the ROS contain symptoms that were F. Abdominal Pain
already mentioned by the patient in the HPI?
Asthma is diagnosed with a device called ___.
Consider the following: You are working at a facility
where the nurse completes the ROS for the patient. Match the following terms with the correct definition:
However, when you enter the room with the doctor, Comorbidity
you notice that one of the patient’s answers Etiology
contradicts the ROS recorded by the nurse. What Diastole
should you do? Polydipsia
A. Approach the nurse directly and ask him to Anticoagulant
correct the ROS
B. Wait until you exit the patient room and Label the following blood pressure readings as
notify the doctor of the discrepancy hypotensive, normal, pre-hypertensive or
C. Ignore the discrepancy. Your EHR doesn’t hypertensive:
allow you to change the nurse’s A. 80/50
documentation B. 100/70
D. Wait for a pause during the patient interview C. 150/95
and notify the doctor of the discrepancy. D. 130/85

True/False: Every HPI starts with the age and sex of What is the name for the study that diagnoses CAD?
the patient as the patient identifies.
If the patient says, “I’ve had open heart surgery,”
What is the abbreviation for hydrochlorothiazide? what would you write in the past medical history
section?
Order the following surgeries based on invasiveness
(1 - least / 4 - most) Which physical exam finding closely associated with
A. CABG asthma?
B. Angioplasty
C. Cardiac catheterization How many months must a patient have a disease for
D. Stent it to be considered chronic?

Complete the sentences for the four questions a
physician likely is to ask any new patient with
asthma.
A. Do you have a home ____?
B. Have you been prescribed ___ recently?
C. Have you been previously ___ for asthma?
D. Have you ever needed to have an __ for
asthma?
Patients with HTN often become symptomatic when
the HTN is chronic and worsening. Which of the
Which of the following examples explain why patients
with comorbidities are complex? (multiple answers)
A. If both illnesses affect a specific organ
system, there is increased risk of organ
failure
B. Adverse drug interactions
C. Treatment of one disease may affect or
contradict the treatment of another
D. Compounding symptoms may lead to poor
compliance with treatment plan
E. None of the above
Complex patients often bill to a ___ level so it is C. Coronary
important to document thoroughly and accurately.
Which of the following are brand name HLD
Which of the following are examples of medications? (Multiple answers)
non-pharmacological HTN management? (multiple A. Lipitor
answers) B. Crestor
A. Decreased ETOH intake C. Humalog
B. Low sodium diet D. Symbicort
C. Exercise E. Metformin
D. Smoking cessation
E. Blood pressure log Which of the following are CAD risk factors?
F. Forgetting to take your BP medication daily A. HTN, HLD, Asthma
B. FHx of CAD, <55 y/o, CVA, smoking
Majority of diabetes patients have ___ diabetes. C. HTN, DM, HLD
D. Smoking, ETOH abuse, Obesity
What are three common symptoms of diabetes?
A. Blurred vision, nausea, CP True/False: Exercise and weight loss are examples of
B. Unexpected weight loss/gain, headaches, non-pharmacological treatments for CAD.
neck pain
C. Lower extremity swelling, paresthesias, In what units is peak flow measured?
blurred vision A. % Room Air
D. Polyuria, polydipsia, abdominal pain B. Ounces
C. Liters per minute
Which of the following are disease that can be D. mL
directly caused by diabetes (multiple answers)?
A. Gallstones Which of the following are asthma medications that
B. Retinopathy can be inhaled? (multiple)
C. Renal Failure A. Furosemide
D. Peripheral neuropathy B. Symvastatin
E. Liver failure C. Albuterol
D. Atrovent
True/False: Instead of diet and exercise, Metformin is E. Flovent
the preferred treatment for someone with minimal,
new-onset, type II diabetes. True/False: A nebulizer gives a one time dose of
asthma medication whereas an inhaler delivers
What is considered the “good” type of cholesterol? continuous treatment over a period of time.

True/False: Obesity and high lipid deity and risk Match the following observations with an exam
factors for HLD. system:
A. Breathing comfortable vs respiratory disease
CAD and MI can be caused by HLD due to the B. Alert, normal speech, answer questions
atherosclerosis of the _____ arteries appropriately
A. Femoral C. White vs yellow sclera, conjunctival injection
B. Carotid D. Is the patient in pain? Well-nourished vs
C. Coronary thin/obese

TIA and CVA can be caused by HLD due to Match the description of the term to the
atherosclerosis of the ____ arteries. corresponding physical exam finding:
A. Femoral [ Somnolent, pitting pedal edema, paraspinal
B. Carotid tenderness, thyromegaly, urticaria, 2+ patellar
reflexes, cyanosis, scleral icterus, rebound H. Respiratory
tenderness]
A. Hives/Wheals Define the following terms:
B. Knee reflexes intact and normal A. Palpation
C. Decreased level of consciousness B. Auscultation
D. Swelling of the lower extremities, measure C. Medial
on a scale of trace to 4° D. Diffuse
E. Blue color of the skin caused by lack of blood E. Cachectic
flow
F. Tenderness to palpation of the muscles lining Match the vital sign with the normal range:
the spine [ 60 to 100 bpm, 95-100%, 97.8 - 100.4°F, 90/160 to
G. Yellowing of the eyes 120/80, 12-16 ]
H. Enlarged thyroid A. Oxygen saturation
I. Pain upon removal of pressure B. Blood pressure
C. Heart rate
Match the description of the term to the D. Temperature
corresponding physical exam finding: E. Respiratory rate
[Melena, tachypnea, tachycardia, 5/5 strength in
bilateral upper extremities, angioedema, oriented 4x] If a doctor auscultates a patient’s back, which body
A. Black stool on glove system is he evaluating?
B. Heart rate greater than 100 A. Cardiovascular System
C. Oriented to person, place, time and situation B. Respiratory/Pulmonary System
D. Fast breathing rate C. Digestive System
E. Facial swelling D. Integumentary system
F. Normal motor strength in the upper
extremities. Which of the following tools are used to evaluate the
eyes?
Match the body system with the corresponding A. Ultrasound
physical exam term: B. Stethoscope
[Pharyngeal erythema, angioedema, CVA tenderness, C. Ophthalmoscope
TM erythema, Cachectic, Carotid bruit]
A. HEENT (Eyes) True/False: It is not important to document that the
B. Back patient is producing tears when crying in pediatric
C. Neck patients.
D. Constitutional
E. HEENT (Throat) The assessment will always include a ___.
F. HEENT (Ears)
What does a “simple statement” assessment have?
Match the body system with the corresponding
physical exam term: Define the following terms:
[ Melena, Pedal edema, Rales, McBurney’s point Subq
tenderness, Irregularly irregular, epistaxis, Alert and Follow-up
oriented x4, Urticaria] Prognosis
A. Musculoskeletal prn
B. Rectal BID
C. Cardiovascular
D. Skin Which of the following items are included in the plan
E. Neurological for a patient?
F. HEENT (Nose) A. Studies/tests ordered today
G. Abdomen B. Lifestyle changes such as diet or exercise
 C. OTC medications A patient visits the clinic with a CC of sore throat. The
D. Prescriptions ordered today provider orders a rapid strep test ad a monospot
E. Recommended treatments for each diagnosis which are both negative, and he diagnoses the patient
F. Follow Up with other healthcare with a viral syndrome. Do the rapid strep and
professionals monospot result belong in the assessment?
G. All the above A. Yes
B. No
Which of the following items are included in a
“comprehensive summary” assessment? Where does the plan appear in the chart?
A. Summary of results
B. Diagnosis In which format is the plan typically given?
C. Age and sex of the patient A. Checkbox template
D. Summary of PE B. Single sentence
E. All the above C. Paragraph
D. Bulleted list
Which of the following should you include for each
result included in the assessment? True/False: Providers often dictate their plan
A. Name of the test verbatim to the patient in the room, so it's important
B. Why the test was ordered to listen to the entire conversation between provider
C. Result of the test and patient.
D. All of the answers
Define the following terms
True/False: If the provider is not able to determine a ICD
definitive diagnosis during the visit, they will include Superbill
a differential diagnosis in the assment. LOS
I-house
True/False: The assessment is typically written in
complete sentences. Label the patient below with low or moderate risk:
A. No PMHx, here for ankle sprain
Which of the following are examples of lab results? B. Asthma with recent exacerbation
(multiple) C. Check-up for HTN and DM management
A. Urine
B. BMP Match the following elements for a Level 4
C. CBC requirement with corresponding type of patient
D. Coagulations (new/established):
E. Humalog A. # of ROS
B. # of PMHX elements
Which of the following are NOT examples of imaging C. # of HPI elements
studies? D. # of PE systems
A. US E. # of A/P elements
B. CT 1. New - 4 / Established - 2
C. XR 2. New - 1 / Established - 2
D. MRI 3. New - 10/ Established - 2
E. Troponin 4. New - 3 / Established - 1
5. New - 10 or 18(9) / Established - 2 or 12(2)
True/False: Negative results should not be included
in the assessment because they are never pertinent to Which of the following items must be documented in
the diagnosis. order to bill for counseling? (multiple)
A. The provider’s favorite restaurant
B. Percentage of visit spent on counseling
 C. Cigarette brand preferences A. < 50%
D. Total time spent with the patient B. 5 minutes
C. > 50%
A new patient has had no care by any member of the ICD codes correspond to:
billing physician’s specialty or practice group within A. Billing level
the past ___ years. B. In-house labs
A. 1 C. Past medical records
B. 2 D. Diagnosis
C. 3
D. 4 True/False: Every chart must have an E&M code
because the E&M code determines the level of
During today’s appointment PMD Dr. Hill referred reimbursement for the visit.
Mary to Dr. Ruby, a rheumatologist within his same
physician group. When Mary visits Dr. Ruby next
month, will she be considered a new or established
patient?
A. New
B. Established

Which type of patient requires a more detailed chart

in order to bill to the same level?
A. Established
B. New

True/False: E&M stands for evaluation and

management and determines the amount of eligible
reimbursement for the office visit.

What are the two most commonly used E&M levels in

outpatient medicine?
A. 4 and 5
B. 2 and 3
C. 1 and 2
D. 3 and 4

True/False: If you document “reviewed past history”

for an established patient, you must also document
the date of last visit in order for it to count as a
billable PMHx.

Which is not considered a “subsection” of assessment

and plan?
A. Data
B. Problems
C. Follow up
D. Health risk

If ____ of the patient encounter is spent with

face-to-face counseling, the provider can bill for
counseling time.