SCRIBEAMERICA FINAL EXAM TEST BANK
2026 FULL SOLUTION SET
⫸ What is the scope of a scribe? Answer: An unlicensed person
performing documentation and other non-clinical tasks under the
direction of a healthcare provider.
⫸ Are physician assistants and nurse practitioners considered medical
providers? Answer: No, they are mid-level provider.
⫸ T/F: The scribe can listen to a patient's heart and lungs as long as it is
for learning purposes and under supervision of the physician. Answer:
FALSE
⫸ What will the scribe document for the outpatient visit? Answer:
Document the history, physical exam, results, procedures, assessment,
and plan.
⫸ Lucy has been seen by Dr. Heart for the past 2 years. She is here
today for a routine appointment with Dr. Heart. Is Lucy a new or
established patient? Answer: Established
⫸ A patient made an appointment because she developed a rash a few
days ago. What type of visit would this be? Answer: Diagnostic
,⫸ A patient has an appointment for management of her diabetes. What
type of visit would this be? Answer: Health Management
⫸ Who is the first person to speak with the patient after is he/she is
placed in a room? Answer: Physician
⫸ What are the meaningful use requirements the nurse/MA will obtain?
Answer: Chief complaint, vital signs (HR, BP, T, RR), height, weight,
BMI, smoking status
⫸ What does H&P abbreviate and who perform this evaluation?
Answer: History and physical, physician evaluation
⫸ Is a differential diagnosis necessary for a health management visit?
Answer: No, only for diagnostic visit. (Possible Dx that may be causing
the symptoms)
⫸ What information will be included in the patient's plan? Give three
examples. Answer: Follow-up with specialist if necessary, instructions
for lifestyle and preventative care, and follow-up for next routine
appointment.
⫸ At what age would a family member's cardiac disease indicate an
increased risk for similar heart disease in the patient? Answer: MI/CAD
less than 55 y/o
, ⫸ What are three common general family histories your physician may
ask about? Answer: HTN, DM, CA
⫸ Would PMHx of chronic alcoholism belong in the SHx section as
well as the PMHx section? Answer: Social History (SHx)
⫸ Why must smoking status be documented on every patient 13 years
and older? Answer: Meaningful use requirement.
⫸ Name the three most common routes of administration of illicit
drugs. Answer: oral, inhaled, injection
⫸ The patient's mother states, "The daycare called me to pick up Angela
and her brother because Angela had a fever." What are three items you
can document under social history for Angela? Answer: Mother (brought
in and caretaker), goes to Daycare, has a brother.
⫸ If a patient has had respiratory symptoms for the past 5 weeks, are the
symptoms considered chronic? Answer: No. An illness is typically
classified as chronic when it lasts longer than 3months.
⫸ What is a comorbidity? Answer: Patients with comorbidities are
complex in a number of ways: The treatment of one disease may affect
or contradict the treatment of the second; adverse drug interactions;
2026 FULL SOLUTION SET
⫸ What is the scope of a scribe? Answer: An unlicensed person
performing documentation and other non-clinical tasks under the
direction of a healthcare provider.
⫸ Are physician assistants and nurse practitioners considered medical
providers? Answer: No, they are mid-level provider.
⫸ T/F: The scribe can listen to a patient's heart and lungs as long as it is
for learning purposes and under supervision of the physician. Answer:
FALSE
⫸ What will the scribe document for the outpatient visit? Answer:
Document the history, physical exam, results, procedures, assessment,
and plan.
⫸ Lucy has been seen by Dr. Heart for the past 2 years. She is here
today for a routine appointment with Dr. Heart. Is Lucy a new or
established patient? Answer: Established
⫸ A patient made an appointment because she developed a rash a few
days ago. What type of visit would this be? Answer: Diagnostic
,⫸ A patient has an appointment for management of her diabetes. What
type of visit would this be? Answer: Health Management
⫸ Who is the first person to speak with the patient after is he/she is
placed in a room? Answer: Physician
⫸ What are the meaningful use requirements the nurse/MA will obtain?
Answer: Chief complaint, vital signs (HR, BP, T, RR), height, weight,
BMI, smoking status
⫸ What does H&P abbreviate and who perform this evaluation?
Answer: History and physical, physician evaluation
⫸ Is a differential diagnosis necessary for a health management visit?
Answer: No, only for diagnostic visit. (Possible Dx that may be causing
the symptoms)
⫸ What information will be included in the patient's plan? Give three
examples. Answer: Follow-up with specialist if necessary, instructions
for lifestyle and preventative care, and follow-up for next routine
appointment.
⫸ At what age would a family member's cardiac disease indicate an
increased risk for similar heart disease in the patient? Answer: MI/CAD
less than 55 y/o
, ⫸ What are three common general family histories your physician may
ask about? Answer: HTN, DM, CA
⫸ Would PMHx of chronic alcoholism belong in the SHx section as
well as the PMHx section? Answer: Social History (SHx)
⫸ Why must smoking status be documented on every patient 13 years
and older? Answer: Meaningful use requirement.
⫸ Name the three most common routes of administration of illicit
drugs. Answer: oral, inhaled, injection
⫸ The patient's mother states, "The daycare called me to pick up Angela
and her brother because Angela had a fever." What are three items you
can document under social history for Angela? Answer: Mother (brought
in and caretaker), goes to Daycare, has a brother.
⫸ If a patient has had respiratory symptoms for the past 5 weeks, are the
symptoms considered chronic? Answer: No. An illness is typically
classified as chronic when it lasts longer than 3months.
⫸ What is a comorbidity? Answer: Patients with comorbidities are
complex in a number of ways: The treatment of one disease may affect
or contradict the treatment of the second; adverse drug interactions;
