What medical term describes the surgical removal of the gallbladder? Cholecystectomy What does "PHI" stand for? Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. False A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? Craniotomy A patient's PCP is on vacation. The patient is scheduled to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP before. Is this patient considered a new patient or an established patient? Established A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physician discusses 4-5 different back stretching exercises that the patient can perform every morning and before doing any heavy lifting. The discussion only takes 10 minutes of a 15 minute Established Patient visit. Would your physician be able to bill counseling time on this patient? Yes What medical term would best describe "the likely course or outcome of a disease"? Prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have"? PHx You are writing an HPI for a patient who presented for hyperlipidemia management. In the middle of the visit, your patient also reports having recently experienced urinary symptoms. Which HPI structure would be the best to use in this scenario? Multiple complaints structure Which of the following is NOT a purpose of HITECH? 1. To require equal access, opportunity, and affordability for health insurance plans by screening patient health information 2. To require government accountability on health insurance plans available in the market place 3. To require encryption when using technology to transmit patient related information 4. To require patient accountability in paying for their health care visit What medical term would describe a patient with a history of infection or inflammation of the liver? Hepatitis For correct billing and reimbursement to go through, a counseling note requires docuementation of the following: