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

BMP stands for Basic Metabolic Panel, a common lab order that includes electrolytes, BUN, creatinine, and glucose.

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

The physician's interpretation of a lab value as evidence for a clinical condition belongs in the assessment section.

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

Accurate documentation of the test name, result, and the clinical action taken ensures a complete and legally defensible record.

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

Point-of-care results should be documented with the exact value and the physician's clinical interpretation; 48 mg/dL represents hypoglycemia.

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

A baseline study is ordered to establish a reference point against which future results can be compared.

CPMS - Certified Professional Medical Scribe Practice Test