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

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?

Accepted Answer

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

Answer

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)?

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

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?

Accepted Answer

Pupils equal, round, reactive to light and accommodation.

Answer

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)?

Accepted Answer

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

Answer

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.

CPMS - Certified Professional Medical Scribe Practice Test

CPMS - Certified Professional Medical Scribe Practice Test

FREE CPMS Clinical Encounter Documentation Questions and Answers