MS Medical Scribe Terminology & Documentation 3 — Questions and Answers
Question 1: Which ICD-10 code category is used to document a patient's encounter for a well-child visit with no complaints?
- Z codes (Correct answer)
- V codes
- E codes
- S codes
Correct answer: Z codes
Z codes in ICD-10 are used for encounters not due to illness or injury, including preventive visits and screenings.
Question 2: A physician documents 'edema 2+ bilateral lower extremities.' What does 'bilateral' mean?
- One-sided
- Both sides (Correct answer)
- Intermittent
- Severe
Correct answer: Both sides
Bilateral means affecting both sides of the body; in this case, swelling is present in both legs.
Question 3: When documenting a review of systems (ROS), which of the following would be recorded as a 'positive finding'?
- Patient denies headache
- Patient reports nausea for 3 days (Correct answer)
- No fever noted
- Normal bowel movements reported
Correct answer: Patient reports nausea for 3 days
A positive finding in ROS means the patient confirms experiencing that symptom, such as reporting nausea.
Question 4: What is the correct way to document time in a medical record to avoid ambiguity?
- 3:00 PM
- 1500 (Correct answer)
- 3 o'clock afternoon
- PM 3:00
Correct answer: 1500
Medical records use 24-hour (military) time to eliminate confusion between AM and PM, so 3:00 PM is written as 1500.
Question 5: Which term refers to a new or worsening symptom that arises in a patient who is already hospitalized for a different condition?
- Comorbidity
- Nosocomial complication (Correct answer)
- Iatrogenic effect
- Secondary diagnosis
Correct answer: Nosocomial complication
A nosocomial complication is one that develops during a hospital stay and was not present on admission.
Question 6: A scribe documents 'patient is febrile.' What clinical finding supports this documentation?
- Temperature of 97.8°F
- Temperature of 100.4°F or higher (Correct answer)
- Heart rate of 102 bpm
- Blood pressure of 140/90
Correct answer: Temperature of 100.4°F or higher
Febrile means having a fever; the standard threshold for fever in adults is a temperature of 100.4°F (38°C) or higher.
Question 7: In an operative report, what section describes the step-by-step actions taken by the surgeon during a procedure?
- Pre-operative diagnosis
- Procedure (Correct answer)
- Post-operative diagnosis
- Findings
Correct answer: Procedure
The Procedure section of an operative report narrates the surgical technique and steps performed chronologically.
MS Medical Scribe Terminology & Documentation 3
Which ICD-10 code category is used to document a patient's encounter for a well-child visit with no complaints?