CPMS Diagnostic Testing and Procedures Documentation 3

Question 1

A physician says 'Order a BMP and UA with reflex culture.' The scribe recognizes 'BMP' as:

Accepted Answer

Basic Metabolic Panel

Answer

Bone Marrow Puncture

Answer

Blood Morphology Profile

Answer

Bilateral Membrane Pressure

Question 2

The physician reviews a hemoglobin A1c result of 9.2% and says 'poorly controlled diabetes.' The scribe should document this under:

Accepted Answer

Assessment, noting the physician's clinical interpretation of the A1c result

Answer

Chief complaint

Answer

Review of systems

Answer

Plan only, as a future goal

Question 3

When documenting the result of a rapid strep test, which of the following pieces of information is most critical to include?

Accepted Answer

The result (positive/negative), the test name, and the physician's response to the result

Answer

The price billed for the test

Answer

The patient's preferred pharmacy

Answer

The nurse who collected the throat swab

Question 4

A physician performs a bedside glucose check using a glucometer. The reading is 48 mg/dL. The scribe should document this as:

Accepted Answer

A point-of-care glucose of 48 mg/dL (hypoglycemia), consistent with the physician's stated findings

Answer

A normal fasting glucose result

Answer

A critical value to be ignored until lab confirms

Answer

An estimated glucose without recording the value

Question 5

Which term describes a diagnostic test ordered to establish an initial reference value for a patient's condition over time?

Accepted Answer

Baseline study

Answer

STAT order

Answer

Reflex test

Answer

Pre-authorization

Question 6

When a physician documents 'unremarkable CT chest,' the scribe understands this to mean:

Accepted Answer

No significant or abnormal findings were identified on the CT

Answer

The CT was not completed due to patient refusal

Answer

The CT images were of poor quality

Answer

The CT showed an incidental finding requiring follow-up

Question 7

A physician orders a lipid panel and states it should be a 'fasting specimen.' The scribe's role in documentation is to:

Accepted Answer

Record the physician's order including the fasting requirement in the order section

Answer

Educate the patient about fasting requirements

Answer

Draw the blood sample after verifying the patient is fasting

Answer

Calculate the patient's LDL from the result