Scribe America Operational (OP)Final
Exam: Newest Update 2026/2027| A
Comprehensive Review of 200 Real Practice
Questions with Multichoice Answers and
Clinical Rationale| Pass Guaranteed
Introduction
This comprehensive practice examination consists of 200 multiple-choice
questions designed to assess your knowledge of medical scribing fundamentals,
HIPAA compliance, medical terminology, billing and coding, clinical
documentation standards, and healthcare quality initiatives. These questions are
based on the Scribe America Operational Final curriculum and cover essential
concepts required for successful scribe practice in clinical settings.
Question 1
What medical term describes the surgical removal of the gallbladder?
A) Cholecystectomy
B) Cholecystitis
C) Choledochotomy
D) Cholangitis
Answer: A) Cholecystectomy
Rationale: Cholecystectomy is the correct medical term for surgical removal of
the gallbladder. "Chole" refers to bile/gallbladder, "cyst" refers to bladder/sac, and
"ectomy" means surgical removal. Option B (cholecystitis) refers to inflammation
of the gallbladder, Option C (choledochotomy) refers to incision into the common
bile duct, and Option D (cholangitis) refers to inflammation of the bile ducts.
,Question 2
What does "PHI" stand for in healthcare documentation?
A) Personal Health Information
B) Protected Health Information
C) Patient Hospital Identifier
D) Primary Healthcare Institution
Answer: B) Protected Health Information
Rationale: PHI stands for Protected Health Information, which is any information
about health status, provision of healthcare, or payment for healthcare that can be
linked to a specific individual. This is a key concept under HIPAA regulations.
Question 3
True or False: Sharing information about a case with family is allowed, as long as
you are scribing with the physician assigned to the case.
A) True
B) False
Answer: B) False
Rationale: Sharing patient information with family members without proper
authorization is a violation of HIPAA regulations. Even when scribing with the
assigned physician, scribes must maintain patient confidentiality and should only
share information with authorized healthcare personnel involved in the patient's
care.
Question 4
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
Past Surgical History (PSHx) would you record into the chart?
A) Craniectomy
B) Craniotomy
,C) Cranioplasty
D) Craniosynostosis
Answer: B) Craniotomy
Rationale: Craniotomy is the surgical procedure where a portion of the skull is
temporarily removed to access the brain, typically performed to treat bleeding,
tumors, or other intracranial conditions. Craniectomy involves removing a portion
of the skull permanently, cranioplasty is repair of skull defects, and
craniosynostosis is a congenital condition of skull suture fusion.
Question 5
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?
A) New patient
B) Established patient
Answer: B) Established patient
Rationale: According to E&M coding guidelines, a patient is considered
established if they have received professional services from the physician or
another physician of the same specialty in the same group practice within the past
three years. Since the NP is covering for the PCP within the same practice, the
patient retains established status.
Question 6
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?
, A) Yes
B) No
Answer: A) Yes
Rationale: For billing based on counseling time, documentation must include total
time spent with the patient and the percentage of time spent
counseling/coordinating care. Since more than 50% of the visit (10 of 15 minutes)
was spent on counseling, the physician can bill based on time for this established
patient visit.
Question 7
What medical term would best describe "the likely course or outcome of a
disease"?
A) Diagnosis
B) Prognosis
C) Etiology
D) Pathogenesis
Answer: B) Prognosis
Rationale: Prognosis refers to the predicted course and outcome of a disease,
including the likelihood of recovery, complications, and long-term effects.
Diagnosis is identification of the disease, etiology is the cause, and pathogenesis is
the development and progression of the disease.
Question 8
Which section of the chart should you document when you hear the following cue:
"what medical problems do you have"?
A) HPI
B) PMHx
C) ROS
D) PE
Exam: Newest Update 2026/2027| A
Comprehensive Review of 200 Real Practice
Questions with Multichoice Answers and
Clinical Rationale| Pass Guaranteed
Introduction
This comprehensive practice examination consists of 200 multiple-choice
questions designed to assess your knowledge of medical scribing fundamentals,
HIPAA compliance, medical terminology, billing and coding, clinical
documentation standards, and healthcare quality initiatives. These questions are
based on the Scribe America Operational Final curriculum and cover essential
concepts required for successful scribe practice in clinical settings.
Question 1
What medical term describes the surgical removal of the gallbladder?
A) Cholecystectomy
B) Cholecystitis
C) Choledochotomy
D) Cholangitis
Answer: A) Cholecystectomy
Rationale: Cholecystectomy is the correct medical term for surgical removal of
the gallbladder. "Chole" refers to bile/gallbladder, "cyst" refers to bladder/sac, and
"ectomy" means surgical removal. Option B (cholecystitis) refers to inflammation
of the gallbladder, Option C (choledochotomy) refers to incision into the common
bile duct, and Option D (cholangitis) refers to inflammation of the bile ducts.
,Question 2
What does "PHI" stand for in healthcare documentation?
A) Personal Health Information
B) Protected Health Information
C) Patient Hospital Identifier
D) Primary Healthcare Institution
Answer: B) Protected Health Information
Rationale: PHI stands for Protected Health Information, which is any information
about health status, provision of healthcare, or payment for healthcare that can be
linked to a specific individual. This is a key concept under HIPAA regulations.
Question 3
True or False: Sharing information about a case with family is allowed, as long as
you are scribing with the physician assigned to the case.
A) True
B) False
Answer: B) False
Rationale: Sharing patient information with family members without proper
authorization is a violation of HIPAA regulations. Even when scribing with the
assigned physician, scribes must maintain patient confidentiality and should only
share information with authorized healthcare personnel involved in the patient's
care.
Question 4
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
Past Surgical History (PSHx) would you record into the chart?
A) Craniectomy
B) Craniotomy
,C) Cranioplasty
D) Craniosynostosis
Answer: B) Craniotomy
Rationale: Craniotomy is the surgical procedure where a portion of the skull is
temporarily removed to access the brain, typically performed to treat bleeding,
tumors, or other intracranial conditions. Craniectomy involves removing a portion
of the skull permanently, cranioplasty is repair of skull defects, and
craniosynostosis is a congenital condition of skull suture fusion.
Question 5
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?
A) New patient
B) Established patient
Answer: B) Established patient
Rationale: According to E&M coding guidelines, a patient is considered
established if they have received professional services from the physician or
another physician of the same specialty in the same group practice within the past
three years. Since the NP is covering for the PCP within the same practice, the
patient retains established status.
Question 6
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?
, A) Yes
B) No
Answer: A) Yes
Rationale: For billing based on counseling time, documentation must include total
time spent with the patient and the percentage of time spent
counseling/coordinating care. Since more than 50% of the visit (10 of 15 minutes)
was spent on counseling, the physician can bill based on time for this established
patient visit.
Question 7
What medical term would best describe "the likely course or outcome of a
disease"?
A) Diagnosis
B) Prognosis
C) Etiology
D) Pathogenesis
Answer: B) Prognosis
Rationale: Prognosis refers to the predicted course and outcome of a disease,
including the likelihood of recovery, complications, and long-term effects.
Diagnosis is identification of the disease, etiology is the cause, and pathogenesis is
the development and progression of the disease.
Question 8
Which section of the chart should you document when you hear the following cue:
"what medical problems do you have"?
A) HPI
B) PMHx
C) ROS
D) PE
