ScribeAmerica Medical Scribe Comprehensive Exam Prep |
EHR Documentation, Medical Terminology & Clinical Practice
QUESTIONs and answers 2026/2027
QUESTION 1 What is the primary role of a medical scribe in a clinical
practice or emergency department?
• A. To diagnose patients and prescribe medications under physician
supervision
• B. To perform real-time electronic health record (EHR)
documentation and administrative support under direct provider
supervision
• C. To triage patients upon arrival and obtain independent vital
signs
• D. To manage medical billing and file insurance claims directly
Correct Answer: B. To perform real-time electronic health record (EHR)
documentation and administrative support under direct provider
supervision
Detailed Rationale: Medical scribes are non-clinical administrative
assistants whose primary function is to document patient encounters in
real time within the EHR, freeing the provider to focus entirely on
patient care.
QUESTION 2 Which federal law sets the national standards for
protecting sensitive patient health information and privacy?
• A. Emergency Treatment and Labor Act (EMTALA)
, • B. Health Insurance Portability and Accountability Act (HIPAA)
• C. Patient Protection and Affordable Care Act (ACA)
• D. Fair Labor Standards Act (FLSA)
Correct Answer: B. Health Insurance Portability and Accountability Act
(HIPAA)
Detailed Rationale: HIPAA establishes strict federal guidelines and
privacy rules (such as the Privacy Rule and Security Rule) to safeguard
Protected Health Information (PHI).
QUESTION 3 In SOAP note documentation, which section contains the
patient's subjective statements, including the Chief Complaint and
History of Present Illness?
• A. Subjective
• B. Objective
• C. Assessment
• D. Plan
Correct Answer: A. Subjective
Detailed Rationale: The Subjective section captures the patient's
perspective, symptoms, history of present illness, review of systems,
and past medical history as reported directly by the patient or historian.
QUESTION 4 What does the acronym OLDCARTS stand for in medical
history taking?
• A. Onset, Location, Duration, Character, Alleviating/Aggravating
factors, Radiation, Timing, Severity
, • B. Oxygen Level, Diagnosis, Care, Acute Response, Treatment,
Symptoms
• C. Output, Lab Data, Charting, Assessment, Review, Testing, Score
• D. Observation, Localized Pain, Clinical Action, Respiratory Status
Correct Answer: A. Onset, Location, Duration, Character,
Alleviating/Aggravating factors, Radiation, Timing, Severity
Detailed Rationale: OLDCARTS is the standard mnemonic used by
scribes and clinicians to ensure every element of the History of Present
Illness (HPI) is thoroughly detailed.
QUESTION 5 What does the medical prefix "brady-" signify when used
in clinical terminology?
• A. Fast or rapid
• B. Slow
• C. Difficult or painful
• D. Excessive or above normal
Correct Answer: B. Slow
Detailed Rationale: The prefix "brady-" means slow (e.g., bradycardia
means a slow heart rate). Conversely, "tachy-" means fast.
QUESTION 6 What is the medical suffix that means surgical removal or
excision?
• A. -ostomy
• B. -otomy
• C. -ectomy
, • D. -plasty
Correct Answer: C. -ectomy
Detailed Rationale: The suffix "-ectomy" denotes surgical removal (e.g.,
appendectomy, cholecystectomy). "-otomy" means cutting into, and "-
ostomy" creates an opening.
QUESTION 7 What is the medical term for high blood pressure?
• A. Hypotension
• B. Hypertension
• C. Hyperglycemia
• D. Hyperlipidemia
Correct Answer: B. Hypertension
Detailed Rationale: Hypertension is persistently elevated blood
pressure. Hypotension refers to abnormally low blood pressure.
QUESTION 8 Which medical abbreviation is used to indicate a
medication that should be taken twice a day?
• A. QD
• B. BID
• C. TID
• D. QID
Correct Answer: B. BID
Detailed Rationale: BID stands for bis in die, meaning twice a day. TID is
three times a day, and QID is four times a day.
EHR Documentation, Medical Terminology & Clinical Practice
QUESTIONs and answers 2026/2027
QUESTION 1 What is the primary role of a medical scribe in a clinical
practice or emergency department?
• A. To diagnose patients and prescribe medications under physician
supervision
• B. To perform real-time electronic health record (EHR)
documentation and administrative support under direct provider
supervision
• C. To triage patients upon arrival and obtain independent vital
signs
• D. To manage medical billing and file insurance claims directly
Correct Answer: B. To perform real-time electronic health record (EHR)
documentation and administrative support under direct provider
supervision
Detailed Rationale: Medical scribes are non-clinical administrative
assistants whose primary function is to document patient encounters in
real time within the EHR, freeing the provider to focus entirely on
patient care.
QUESTION 2 Which federal law sets the national standards for
protecting sensitive patient health information and privacy?
• A. Emergency Treatment and Labor Act (EMTALA)
, • B. Health Insurance Portability and Accountability Act (HIPAA)
• C. Patient Protection and Affordable Care Act (ACA)
• D. Fair Labor Standards Act (FLSA)
Correct Answer: B. Health Insurance Portability and Accountability Act
(HIPAA)
Detailed Rationale: HIPAA establishes strict federal guidelines and
privacy rules (such as the Privacy Rule and Security Rule) to safeguard
Protected Health Information (PHI).
QUESTION 3 In SOAP note documentation, which section contains the
patient's subjective statements, including the Chief Complaint and
History of Present Illness?
• A. Subjective
• B. Objective
• C. Assessment
• D. Plan
Correct Answer: A. Subjective
Detailed Rationale: The Subjective section captures the patient's
perspective, symptoms, history of present illness, review of systems,
and past medical history as reported directly by the patient or historian.
QUESTION 4 What does the acronym OLDCARTS stand for in medical
history taking?
• A. Onset, Location, Duration, Character, Alleviating/Aggravating
factors, Radiation, Timing, Severity
, • B. Oxygen Level, Diagnosis, Care, Acute Response, Treatment,
Symptoms
• C. Output, Lab Data, Charting, Assessment, Review, Testing, Score
• D. Observation, Localized Pain, Clinical Action, Respiratory Status
Correct Answer: A. Onset, Location, Duration, Character,
Alleviating/Aggravating factors, Radiation, Timing, Severity
Detailed Rationale: OLDCARTS is the standard mnemonic used by
scribes and clinicians to ensure every element of the History of Present
Illness (HPI) is thoroughly detailed.
QUESTION 5 What does the medical prefix "brady-" signify when used
in clinical terminology?
• A. Fast or rapid
• B. Slow
• C. Difficult or painful
• D. Excessive or above normal
Correct Answer: B. Slow
Detailed Rationale: The prefix "brady-" means slow (e.g., bradycardia
means a slow heart rate). Conversely, "tachy-" means fast.
QUESTION 6 What is the medical suffix that means surgical removal or
excision?
• A. -ostomy
• B. -otomy
• C. -ectomy
, • D. -plasty
Correct Answer: C. -ectomy
Detailed Rationale: The suffix "-ectomy" denotes surgical removal (e.g.,
appendectomy, cholecystectomy). "-otomy" means cutting into, and "-
ostomy" creates an opening.
QUESTION 7 What is the medical term for high blood pressure?
• A. Hypotension
• B. Hypertension
• C. Hyperglycemia
• D. Hyperlipidemia
Correct Answer: B. Hypertension
Detailed Rationale: Hypertension is persistently elevated blood
pressure. Hypotension refers to abnormally low blood pressure.
QUESTION 8 Which medical abbreviation is used to indicate a
medication that should be taken twice a day?
• A. QD
• B. BID
• C. TID
• D. QID
Correct Answer: B. BID
Detailed Rationale: BID stands for bis in die, meaning twice a day. TID is
three times a day, and QID is four times a day.
