Diagnostic Testing and Procedures Documentation Flashcards
7 cards from real CPMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Diagnostic Testing and Procedures Documentation flashcards as text
A physician says 'Order a BMP and UA with reflex culture.' The scribe recognizes 'BMP' as:
Answer: Basic Metabolic Panel
BMP stands for Basic Metabolic Panel, a common lab order that includes electrolytes, BUN, creatinine, and glucose.
The physician reviews a hemoglobin A1c result of 9.2% and says 'poorly controlled diabetes.' The scribe should document this under:
Answer: Assessment, noting the physician's clinical interpretation of the A1c result
The physician's interpretation of a lab value as evidence for a clinical condition belongs in the assessment section.
When documenting the result of a rapid strep test, which of the following pieces of information is most critical to include?
Answer: The result (positive/negative), the test name, and the physician's response to the result
Accurate documentation of the test name, result, and the clinical action taken ensures a complete and legally defensible record.
A physician performs a bedside glucose check using a glucometer. The reading is 48 mg/dL. The scribe should document this as:
Answer: A point-of-care glucose of 48 mg/dL (hypoglycemia), consistent with the physician's stated findings
Point-of-care results should be documented with the exact value and the physician's clinical interpretation; 48 mg/dL represents hypoglycemia.
Which term describes a diagnostic test ordered to establish an initial reference value for a patient's condition over time?
Answer: Baseline study
A baseline study is ordered to establish a reference point against which future results can be compared.
When a physician documents 'unremarkable CT chest,' the scribe understands this to mean:
Answer: No significant or abnormal findings were identified on the CT
'Unremarkable' is a clinical term indicating that no significant abnormalities were found on the imaging study.
A physician orders a lipid panel and states it should be a 'fasting specimen.' The scribe's role in documentation is to:
Answer: Record the physician's order including the fasting requirement in the order section
The scribe documents the order as specified by the physician, including any special requirements such as fasting, without performing clinical tasks.