How many elements should you document to make a clinical physical exam fully billable?
8
400
What information is protected health information (PHI)?
Name, DOB, lab results, MRN, and the fact that the patient was in the ED
400
What would you document if I did this and the patient had no pain/response?
No CVA tenderness bilaterally
400
Define: pruritic
Itchy
400
A patient presents with a headache. She has no focal neurologic deficits and her vitals are WNL. Her CT head and labs are normal. She likely is experiencing a typical migraine. What kind of things should you document as negative diagnoses in the rationale?
No signs of meningitis, no intracranial hemorrhage, no signs of CVA
500
What phrase do you need to add to EKG and cardiac monitor to make it billable?
Interpreted by myself
500
Dr. Roper asks you to silence a monitor, as it is beeping while you are in the room doing a patient evaluation. Would it be okay to perform this task?
No! It is beyond the scope of your job to touch anyone's monitors or any patients.
500
Which of these is a contradiction/doesn't belong?
Skin tending around the medial malleolus consistent with an open fracture, surrounding edema and ecchymosis, no deformity.
No deformity! if there is an open fracture this is a deformity
500
Decode this sentence:
Pt arrives diaphoretic and tachypneic. He is experiencing anterior sub-sternal chest pain. He was medicated with NTG and ASA. CXR, EKG and Troponin were ordered.
Patient arrives sweaty and with an elevated respiratory rate. His chest pain is located in the front of the chest, under the breast bone. He was medicated with nitroglycerin and aspirin. Chest x-ray, electrocardiogram and troponin were ordered.
500
Patient presents with left sided deficits and slurred speech. CT head was reported as negative. What was ruled out and what is still in the differential?
Acute hemorrhagic CVA and mass are ruled out. Ischemic stroke or TIA is still possible