Scribe America Final Exam OP/ Scribe America OP Final
Exam Concept List 2 SETS COMPLIED WITH COMPLETE
SOLUTION UPDATED 2025/2026 NEW EDITION
Scribes CAN - Ans 1. Document the history, physical exam, results, procedures, and physician
consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT - Ans -touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC) - Ans the main reason for the patient's visit
EMR / EHR - Ans Electronic Medical Record / Electronic Health Record
Subjective - Ans feelings of the patient
Objective - Ans factual findings from the provider
,pain - Ans patients feeling of discomfort
tenderness - Ans doctors finding of reproducible pain
acute - Ans New onset, likely concerning
chronic - Ans Long-standing, not of direct concern
new patient (NP) - Ans a patient that has never been seen at the clinic or was seen greater
than 3 years ago.
no previous records.
longer visits.
detailed chart.
established patient (EP) - Ans a patient that has been seen at the clinic by any provider within
the last 3 years.
previous records available.
shorter visits.
concise chart.
,Diagnostic visit - Ans New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit - Ans Check-up,
Chief Complaint: Routine physical or management of chronic problem(s),
and Goal is preventative care and/or assessing progress of ongoing medical problems
History of Present Illness (HPI) - Ans The story and context of the Chief Complaint (subjective)
Review of Systems (ROS) - Ans A head-to-toe list of positives and negatives (subjective)
Past history - Ans PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examination (PE) - Ans The physician's objective findings
Orders and Results - Ans objective evaluation
Assessment - Ans current diagnoses
plan - Ans treatment plan and follow up
, high lblood lpressure l- l Ans l Hypertension l(HTN)
high lcholesterol l- l Ans l Hyperlipidemia l(HLD)
diabetes l- l Ans l Diabetes lMellitus l(DM)
"I lonly ltake lpills lfor lmy ldiabetes" l- l Ans l Non-Insulin lDependent lDiabetes lMellitus l(NIDDM)
"I ltake lshots l(insulin) lfor lmy ldiabetes" l- l Ans l Insulin lDependent lDiabetes lMellitus l(IDDM)
heart ldisease l- l Ans l Coronary lArtery lDisease l(CAD)
heart lattack l- l Ans l Myocardial lInfarction l(MI) land lCAD
heart lfailure l- l Ans l Congestive lHeart lFailure l(CHF)
Irregular lheartbeat l- l Ans l Arrhythmia, lAtrial lFibrillation l(A-Fib)
Emphysema lor lChronic lBronchitis l- l Ans l Chronic lObstructive lPulmonary lDisease l(COPD)
Blood lclot lin llung l- l Ans l Pulmonary lEmbolism l(PE)
pneumonia lor llung linfection l- l Ans l pneumonia l(PNA)
reflux l- l Ans l Gastroesophageal lReflux lDisease l(GERD)
Exam Concept List 2 SETS COMPLIED WITH COMPLETE
SOLUTION UPDATED 2025/2026 NEW EDITION
Scribes CAN - Ans 1. Document the history, physical exam, results, procedures, and physician
consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT - Ans -touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC) - Ans the main reason for the patient's visit
EMR / EHR - Ans Electronic Medical Record / Electronic Health Record
Subjective - Ans feelings of the patient
Objective - Ans factual findings from the provider
,pain - Ans patients feeling of discomfort
tenderness - Ans doctors finding of reproducible pain
acute - Ans New onset, likely concerning
chronic - Ans Long-standing, not of direct concern
new patient (NP) - Ans a patient that has never been seen at the clinic or was seen greater
than 3 years ago.
no previous records.
longer visits.
detailed chart.
established patient (EP) - Ans a patient that has been seen at the clinic by any provider within
the last 3 years.
previous records available.
shorter visits.
concise chart.
,Diagnostic visit - Ans New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit - Ans Check-up,
Chief Complaint: Routine physical or management of chronic problem(s),
and Goal is preventative care and/or assessing progress of ongoing medical problems
History of Present Illness (HPI) - Ans The story and context of the Chief Complaint (subjective)
Review of Systems (ROS) - Ans A head-to-toe list of positives and negatives (subjective)
Past history - Ans PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examination (PE) - Ans The physician's objective findings
Orders and Results - Ans objective evaluation
Assessment - Ans current diagnoses
plan - Ans treatment plan and follow up
, high lblood lpressure l- l Ans l Hypertension l(HTN)
high lcholesterol l- l Ans l Hyperlipidemia l(HLD)
diabetes l- l Ans l Diabetes lMellitus l(DM)
"I lonly ltake lpills lfor lmy ldiabetes" l- l Ans l Non-Insulin lDependent lDiabetes lMellitus l(NIDDM)
"I ltake lshots l(insulin) lfor lmy ldiabetes" l- l Ans l Insulin lDependent lDiabetes lMellitus l(IDDM)
heart ldisease l- l Ans l Coronary lArtery lDisease l(CAD)
heart lattack l- l Ans l Myocardial lInfarction l(MI) land lCAD
heart lfailure l- l Ans l Congestive lHeart lFailure l(CHF)
Irregular lheartbeat l- l Ans l Arrhythmia, lAtrial lFibrillation l(A-Fib)
Emphysema lor lChronic lBronchitis l- l Ans l Chronic lObstructive lPulmonary lDisease l(COPD)
Blood lclot lin llung l- l Ans l Pulmonary lEmbolism l(PE)
pneumonia lor llung linfection l- l Ans l pneumonia l(PNA)
reflux l- l Ans l Gastroesophageal lReflux lDisease l(GERD)
