CPMS Diagnostic Testing and Procedures Documentation 2 — Questions and Answers
Question 1: A physician orders a STAT CT head without contrast. In this context, 'STAT' means the test should be performed:
- Within 24 hours
- At the patient's convenience
- Immediately or as soon as possible (Correct answer)
- During the next available scheduling slot
Correct answer: Immediately or as soon as possible
STAT (from Latin statim) means immediately; it indicates the highest urgency level for diagnostic orders.
Question 2: Which document gives the scribe authority to view and transcribe a patient's diagnostic results during an encounter?
- The patient's insurance card
- The physician's order for the test
- The facility's scribe credentialing agreement and patient consent (Correct answer)
- The laboratory's privacy policy
Correct answer: The facility's scribe credentialing agreement and patient consent
Scribes access PHI under the authority of a credentialing agreement and patient consent processes that satisfy HIPAA requirements.
Question 3: When documenting an EKG interpretation in the medical record, the scribe should record the provider's interpretation as:
- An objective finding in the scribe's own clinical judgment
- The physician's dictated or stated interpretation attributed to them (Correct answer)
- A copy-paste from a prior EKG report
- A direct quote from the EKG machine's automated reading only
Correct answer: The physician's dictated or stated interpretation attributed to them
All interpretations must be attributed to the treating physician, as scribes document what the provider states rather than offering independent clinical interpretations.
Question 4: A patient undergoes a spirometry test in the office. The physician reviews the flow-volume loop and states 'obstructive pattern consistent with COPD.' Where does the scribe document this?
- The past medical history section
- The physical exam section under pulmonary
- The assessment section, as part of the physician's interpretation (Correct answer)
- The billing section only
Correct answer: The assessment section, as part of the physician's interpretation
The physician's interpretation of a diagnostic result belongs in the assessment section, linking findings to the clinical diagnosis.
Question 5: When a lab result is documented as 'pending' in the EHR, what is the scribe's responsibility at the time of the visit?
- Delete the pending notation and re-enter when results arrive
- Document the test as ordered/pending and note the physician's plan to review results (Correct answer)
- Mark the encounter as incomplete and do not submit
- Call the lab to obtain a preliminary result
Correct answer: Document the test as ordered/pending and note the physician's plan to review results
Documenting the test as ordered and the follow-up plan reflects the clinical encounter accurately, even when results are not yet available.
Question 6: Which of the following best describes the scribe's role when a physician performs and documents an in-office procedure like wound irrigation?
- The scribe performs the procedure while the physician documents
- The scribe transcribes the physician's verbal description of the procedure in real time (Correct answer)
- The scribe photographs the wound for the medical record
- The scribe orders the procedural supply kit independently
Correct answer: The scribe transcribes the physician's verbal description of the procedure in real time
The scribe transcribes the physician's spoken account of the procedure, capturing technique, findings, and patient response into the procedure note.
Question 7: A physician documents 'Echo last year showed EF 45%.' As a scribe, you should flag this entry if:
- The patient is over 65 years old
- No date, facility, or source is cited for the referenced echocardiogram (Correct answer)
- The ejection fraction is above 50%
- The patient denies cardiac history
Correct answer: No date, facility, or source is cited for the referenced echocardiogram
Referenced prior diagnostic results should include the date and source to maintain documentation accuracy and support clinical validity.
CPMS Diagnostic Testing and Procedures Documentation 2
A physician orders a STAT CT head without contrast.
In this context, 'STAT' means the test should be performed: