FREE CPMS Clinical Encounter Documentation Questions and Answers

Question 1

A medical scribe is documenting the History of Present Illness (HPI) for a patient with chest pain.
The physician dictates, "The pain is sharp, rated 8/10, started 2 hours ago while mowing the lawn, and radiates to the left arm." According to the 8 standard elements of an HPI, which element is missing from this statement?

Accepted Answer

Modifying Factors

Answer

Location

Answer

Severity

Answer

Context

Question 2

Which of the following is the primary purpose of the Review of Systems (ROS) in clinical documentation?

Accepted Answer

To systematically inventory body systems for any symptoms the patient may have overlooked or not mentioned.

Answer

To provide a detailed, chronological story of the patient's chief complaint.

Answer

To document the objective findings from the physician's physical examination.

Answer

To list the patient's past surgeries, medical conditions, and family health history.

Question 3

A physician reviews a chart documented by a scribe and identifies a factual error in the patient's allergy list. What is the medico-legally appropriate procedure for the scribe or provider to correct this error in the electronic health record (EHR)?

Accepted Answer

Use the 'strikethrough' or 'amend' function to mark the original entry as erroneous and add a new, signed, and dated entry with the correct information.

Answer

Delete the incorrect entry and re-type the correct information.

Answer

Create a new, separate encounter note explaining the correction.

Answer

Overwrite the original incorrect entry with the correct information to keep the chart tidy.

Question 4

In the physical exam section of a patient's chart, a scribe documents "PERRLA" after the physician performs an eye exam. What does this abbreviation signify?

Accepted Answer

Pupils equal, round, reactive to light and accommodation.

Answer

Patient exhibits rapid, rhythmic, lateral eye movements.

Answer

Pupils elevated, round, respond to light and action.

Answer

Patient's eyes react, roll, look, and accommodate.

Question 5

Which of the following represents the most appropriate and compliant way to document the Chief Complaint (CC)?

Accepted Answer

"Patient complains of a sore throat for the past 3 days."

Answer

"Patient presents with symptoms consistent with acute pharyngitis."

Answer

"Follow-up visit."

Answer

"HPI: Sore throat; ROS: Negative for fever; PE: Pharyngeal erythema."

Question 6

A scribe documents the following for a new patient: a detailed HPI (4+ elements), a complete ROS (10+ systems), and a complete PFSH. The physician performs a comprehensive physical exam and demonstrates medical decision making of moderate complexity. Based on the 2021 E/M guidelines, which factor is primarily used to determine the final E/M code level for this office visit?

Accepted Answer

The level of Medical Decision Making (MDM).

Answer

The total number of diagnoses considered.

Answer

The cumulative time spent by the clinical staff.

Answer

The completeness of the documented history and physical exam.