CPMS Diagnostic Testing and Procedures Documentation 2

Question 1

A physician orders a STAT CT head without contrast. In this context, 'STAT' means the test should be performed:

Accepted Answer

Immediately or as soon as possible

Answer

Within 24 hours

Answer

At the patient's convenience

Answer

During the next available scheduling slot

Question 2

Which document gives the scribe authority to view and transcribe a patient's diagnostic results during an encounter?

Accepted Answer

The facility's scribe credentialing agreement and patient consent

Answer

The patient's insurance card

Answer

The physician's order for the test

Answer

The laboratory's privacy policy

Question 3

When documenting an EKG interpretation in the medical record, the scribe should record the provider's interpretation as:

Accepted Answer

The physician's dictated or stated interpretation attributed to them

Answer

An objective finding in the scribe's own clinical judgment

Answer

A copy-paste from a prior EKG report

Answer

A direct quote from the EKG machine's automated reading only

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?

Accepted Answer

The assessment section, as part of the physician's interpretation

Answer

The past medical history section

Answer

The physical exam section under pulmonary

Answer

The billing section only

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?

Accepted Answer

Document the test as ordered/pending and note the physician's plan to review results

Answer

Delete the pending notation and re-enter when results arrive

Answer

Mark the encounter as incomplete and do not submit

Answer

Call the lab to obtain a preliminary result

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?

Accepted Answer

The scribe transcribes the physician's verbal description of the procedure in real time

Answer

The scribe performs the procedure while the physician documents

Answer

The scribe photographs the wound for the medical record

Answer

The scribe orders the procedural supply kit independently

Question 7

A physician documents 'Echo last year showed EF 45%.' As a scribe, you should flag this entry if:

Accepted Answer

No date, facility, or source is cited for the referenced echocardiogram

Answer

The patient is over 65 years old

Answer

The ejection fraction is above 50%

Answer

The patient denies cardiac history