MS Medical Scribe Electronic Health Records (EHR) Management 3 — Questions and Answers
Question 1: A physician dictates a plan that includes 'f/u in 2 weeks.' How should a scribe document this in the EHR?
- f/u in 2 wks
- Follow-up appointment scheduled in two weeks (Correct answer)
- FU2W
- Return visit needed
Correct answer: Follow-up appointment scheduled in two weeks
Scribes should expand abbreviations into full, unambiguous language to prevent misinterpretation by other care team members.
Question 2: The Continuity of Care Document (CCD) in EHR systems is primarily used for:
- Generating billing invoices for insurance submission
- Sharing standardized patient summary data between different healthcare systems (Correct answer)
- Storing raw diagnostic imaging files
- Tracking physician productivity metrics
Correct answer: Sharing standardized patient summary data between different healthcare systems
The CCD is a standardized HL7 document that facilitates interoperability by sharing clinical summaries across different EHR platforms.
Question 3: Which action should a medical scribe take if they realize they have documented information in the wrong patient's chart?
- Quietly delete the entry and re-enter it in the correct chart
- Notify the supervising provider immediately and follow the facility's error correction protocol (Correct answer)
- Leave the entry and add a note in the correct chart
- Log out and log back in to reset the session
Correct answer: Notify the supervising provider immediately and follow the facility's error correction protocol
Wrong-chart documentation is a patient safety event that requires immediate provider notification and formal correction per facility policy.
Question 4: What does the term 'discrete data' mean in the context of EHR documentation?
- Confidential patient information visible only to attending physicians
- Structured, searchable data entered into defined fields such as vital signs or lab values (Correct answer)
- Free-text narrative descriptions of the patient encounter
- Encrypted records stored in an offsite backup server
Correct answer: Structured, searchable data entered into defined fields such as vital signs or lab values
Discrete data is entered into structured fields, making it machine-readable, reportable, and usable for clinical decision support.
Question 5: A provider orders a medication and the EHR generates a drug-allergy interaction alert. The scribe's role is to:
- Override the alert on the provider's behalf to speed up the order
- Dismiss the alert if the patient's allergy is listed as mild
- Bring the alert to the provider's attention for their clinical decision (Correct answer)
- Document the alert as resolved without provider input
Correct answer: Bring the alert to the provider's attention for their clinical decision
Scribes do not have clinical authority to override alerts; they must ensure the provider reviews and acts on any safety alert.
Question 6: Which ICD-10 coding concept requires a scribe to confirm the provider has documented 'acute' versus 'chronic' status of a condition?
- Principal diagnosis selection
- Code specificity and manifestation coding (Correct answer)
- Evaluation and Management (E/M) level selection
- CPT procedure code assignment
Correct answer: Code specificity and manifestation coding
ICD-10 codes often differ based on acuity and chronicity, so accurate provider documentation of these details is essential for correct code assignment.
Question 7: In EHR problem list management, a 'resolved' problem should be:
- Permanently deleted from the chart to reduce clutter
- Moved to the inactive or historical problem list rather than deleted (Correct answer)
- Kept active indefinitely in case the condition recurs
- Transferred to the allergy section for future reference
Correct answer: Moved to the inactive or historical problem list rather than deleted
Resolved problems are moved to the inactive list to preserve historical context while keeping the active problem list clinically current.
MS Medical Scribe Electronic Health Records (EHR) Management 3
A physician dictates a plan that includes 'f/u in 2 weeks.' How should a scribe document this in the EHR?