MS Medical Scribe Terminology & Documentation 3

Question 1

Which ICD-10 code category is used to document a patient's encounter for a well-child visit with no complaints?

Accepted Answer

Z codes

Answer

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?

Accepted Answer

Both sides

Answer

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'?

Accepted Answer

Patient reports nausea for 3 days

Answer

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?

Accepted Answer

1500

Answer

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?

Accepted Answer

Nosocomial complication

Answer

A nosocomial complication is one that develops during a hospital stay and was not present on admission.

(MS) Medical Scribe Certification Practice Test