Free CPMS Clinical Encounter Documentation Questions and Answers — 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?
- Location
- Modifying Factors (Correct answer)
- Severity
- Context
Correct answer: Modifying Factors
The physician's statement includes Quality ('sharp'), Severity ('8/10'), Timing/Duration ('started 2 hours ago'), Context ('while mowing the lawn'), and Radiation ('radiates to the left arm'). However, it is missing Modifying Factors, which are things that make the symptom better or worse (e.g., 'worse with deep breaths,' 'better with rest').
Question 2: Which of the following is the primary purpose of the Review of Systems (ROS) in clinical documentation?
- To provide a detailed, chronological story of the patient's chief complaint.
- To document the objective findings from the physician's physical examination.
- To systematically inventory body systems for any symptoms the patient may have overlooked or not mentioned. (Correct answer)
- To list the patient's past surgeries, medical conditions, and family health history.
Correct answer: To systematically inventory body systems for any symptoms the patient may have overlooked or not mentioned.
The primary purpose of the ROS is to act as a comprehensive inventory of patient-reported symptoms, organized by body system. This helps uncover symptoms not necessarily related to the HPI but potentially significant for diagnosis and overall care.
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)?
- Delete the incorrect entry and re-type the correct information.
- Create a new, separate encounter note explaining the correction.
- 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. (Correct answer)
- Overwrite the original incorrect entry with the correct information to keep the chart tidy.
Correct 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.
The correct procedure for amending an EHR is to create an addendum or use a function that marks the original entry as incorrect without deleting it. The new entry should be dated, timed, and signed by the person making the correction, with a reason for the change. This maintains the integrity of the original record while providing accurate information.
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?
- Patient exhibits rapid, rhythmic, lateral eye movements.
- Pupils elevated, round, respond to light and action.
- Patient's eyes react, roll, look, and accommodate.
- Pupils equal, round, reactive to light and accommodation. (Correct answer)
Correct answer: Pupils equal, round, reactive to light and accommodation.
PERRLA is a standard medical abbreviation used to document a normal pupillary examination. It stands for Pupils Equal, Round, Reactive to Light and Accommodation, indicating that the pupils are symmetrical, circular, constrict appropriately in response to light, and adjust to focus on near objects.
Question 5: Which of the following represents the most appropriate and compliant way to document the Chief Complaint (CC)?
- "Patient presents with symptoms consistent with acute pharyngitis."
- "Follow-up visit."
- "Patient complains of a sore throat for the past 3 days." (Correct answer)
- "HPI: Sore throat; ROS: Negative for fever; PE: Pharyngeal erythema."
Correct answer: "Patient complains of a sore throat for the past 3 days."
The Chief Complaint should be a concise statement describing the reason for the encounter, ideally in the patient's own words. It should state the primary problem and its duration. Documenting a diagnosis (e.g., 'acute pharyngitis') is inappropriate for the CC, and vague statements like 'Follow-up' are non-compliant as they lack specific medical reasoning for the visit.
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?
- The total number of diagnoses considered.
- The level of Medical Decision Making (MDM). (Correct answer)
- The cumulative time spent by the clinical staff.
- The completeness of the documented history and physical exam.
Correct answer: The level of Medical Decision Making (MDM).
As of 2021, the E/M code level for new and established office visits is determined either by the level of Medical Decision Making (MDM) or the total time spent by the provider on the date of the encounter. The extent of history and physical exam are no longer used to select the code level, though a medically appropriate history and exam must still be documented.
Free CPMS Clinical Encounter Documentation Questions and Answers
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?