ScribeAmerica Medical Scribe Final Exam | Complete Practice
QUESTIONs, Correct Answers & Detailed Rationales
(2026/2027)
QUESTION 1 A new medical scribe is working their first shift in the
emergency department. Which of the following actions is strictly
prohibited for a ScribeAmerica medical scribe?
• A. Documenting the provider's physical exam findings in the
electronic health record (EHR)
• B. Looking up laboratory results and radiology reports at the
provider's request
• C. Administering a prescribed intramuscular medication to a stable
patient
• D. Accompanying the physician during patient encounters to
record the history of present illness
Correct Answer: C. Administering a prescribed intramuscular
medication to a stable patient
Detailed Rationale: Scribes are strictly non-clinical assistants. They are
prohibited from touching patients, administering medications, starting
IV lines, handling specimens, or performing any clinical or nursing tasks.
Documenting, looking up charts, and shadowing providers are core
scribe duties.
QUESTION 2 A provider dictates that a patient has inflammation of the
liver. Which of the following medical terms should the scribe record in
the chart?
, • A. Nephritis
• B. Hepatitis
• C. Gastritis
• D. Colitis
Correct Answer: B. Hepatitis
Detailed Rationale: The root "hepat-" refers to the liver, and the suffix
"-itis" denotes inflammation. Therefore, hepatitis is inflammation of the
liver. Nephritis refers to kidney inflammation, gastritis to stomach
inflammation, and colitis to colon inflammation.
QUESTION 3 Which of the following medical abbreviations stands for
"as needed"?
• A. BID
• B. TID
• C. PRN
• D. QHS
Correct Answer: C. PRN
Detailed Rationale: "PRN" stands for pro re nata, which translates to
"as needed." BID means twice a day, TID means three times a day, and
QHS means every night at bedtime.
QUESTION 4 During a physical exam, a physician notes that the patient's
pupils are equal, round, and reactive to light and accommodation.
Which of the following abbreviations should the scribe use?
• A. EOMI
, • B. PERRLA
• C. RRR
• D. AT/NC
Correct Answer: B. PERRLA
Detailed Rationale: PERRLA stands for Pupils Equal, Round, Reactive to
Light, and Accommodation, which is the standard documentation for a
normal eye exam. EOMI stands for Extraocular Movements Intact, RRR
stands for Regular Rate and Rhythm, and AT/NC stands for
Atraumatic/Normocephalic.
QUESTION 5 Which of the following components of the History of
Present Illness (HPI) describes the location, intensity, or sharp/dull
nature of a symptom?
• A. Timing
• B. Quality
• C. Context
• D. Modifying factors
Correct Answer: B. Quality
Detailed Rationale: The "quality" element of an HPI describes the
character of the symptom, such as sharp, dull, throbbing, burning, or
pressure-like. Timing refers to duration or frequency, context describes
what the patient was doing when it started, and modifying factors
describe what makes it better or worse.
, QUESTION 6 A patient presents to the emergency department vomiting
bright red blood. Which of the following medical terms should the
scribe document for this finding?
• A. Hematuria
• B. Hematemesis
• C. Hemoptysis
• D. Melena
Correct Answer: B. Hematemesis
Detailed Rationale: Hematemesis is the medical term for vomiting
blood. Hemoptysis is coughing up blood, hematuria is blood in the
urine, and melena is dark, tarry stools containing digested blood.
QUESTION 7 Under the Health Insurance Portability and Accountability
Act (HIPAA), which of the following actions by a medical scribe is a
direct violation of patient privacy?
• A. Reviewing the chart of a patient assigned to your supervising
physician
• B. Accessing the medical record of a famous celebrity out of
personal curiosity
• C. Discussing de-identified clinical workflow statistics during a
team training meeting
• D. Documenting vital signs called out by a nurse into the EHR
Correct Answer: B. Accessing the medical record of a famous celebrity
out of personal curiosity
QUESTIONs, Correct Answers & Detailed Rationales
(2026/2027)
QUESTION 1 A new medical scribe is working their first shift in the
emergency department. Which of the following actions is strictly
prohibited for a ScribeAmerica medical scribe?
• A. Documenting the provider's physical exam findings in the
electronic health record (EHR)
• B. Looking up laboratory results and radiology reports at the
provider's request
• C. Administering a prescribed intramuscular medication to a stable
patient
• D. Accompanying the physician during patient encounters to
record the history of present illness
Correct Answer: C. Administering a prescribed intramuscular
medication to a stable patient
Detailed Rationale: Scribes are strictly non-clinical assistants. They are
prohibited from touching patients, administering medications, starting
IV lines, handling specimens, or performing any clinical or nursing tasks.
Documenting, looking up charts, and shadowing providers are core
scribe duties.
QUESTION 2 A provider dictates that a patient has inflammation of the
liver. Which of the following medical terms should the scribe record in
the chart?
, • A. Nephritis
• B. Hepatitis
• C. Gastritis
• D. Colitis
Correct Answer: B. Hepatitis
Detailed Rationale: The root "hepat-" refers to the liver, and the suffix
"-itis" denotes inflammation. Therefore, hepatitis is inflammation of the
liver. Nephritis refers to kidney inflammation, gastritis to stomach
inflammation, and colitis to colon inflammation.
QUESTION 3 Which of the following medical abbreviations stands for
"as needed"?
• A. BID
• B. TID
• C. PRN
• D. QHS
Correct Answer: C. PRN
Detailed Rationale: "PRN" stands for pro re nata, which translates to
"as needed." BID means twice a day, TID means three times a day, and
QHS means every night at bedtime.
QUESTION 4 During a physical exam, a physician notes that the patient's
pupils are equal, round, and reactive to light and accommodation.
Which of the following abbreviations should the scribe use?
• A. EOMI
, • B. PERRLA
• C. RRR
• D. AT/NC
Correct Answer: B. PERRLA
Detailed Rationale: PERRLA stands for Pupils Equal, Round, Reactive to
Light, and Accommodation, which is the standard documentation for a
normal eye exam. EOMI stands for Extraocular Movements Intact, RRR
stands for Regular Rate and Rhythm, and AT/NC stands for
Atraumatic/Normocephalic.
QUESTION 5 Which of the following components of the History of
Present Illness (HPI) describes the location, intensity, or sharp/dull
nature of a symptom?
• A. Timing
• B. Quality
• C. Context
• D. Modifying factors
Correct Answer: B. Quality
Detailed Rationale: The "quality" element of an HPI describes the
character of the symptom, such as sharp, dull, throbbing, burning, or
pressure-like. Timing refers to duration or frequency, context describes
what the patient was doing when it started, and modifying factors
describe what makes it better or worse.
, QUESTION 6 A patient presents to the emergency department vomiting
bright red blood. Which of the following medical terms should the
scribe document for this finding?
• A. Hematuria
• B. Hematemesis
• C. Hemoptysis
• D. Melena
Correct Answer: B. Hematemesis
Detailed Rationale: Hematemesis is the medical term for vomiting
blood. Hemoptysis is coughing up blood, hematuria is blood in the
urine, and melena is dark, tarry stools containing digested blood.
QUESTION 7 Under the Health Insurance Portability and Accountability
Act (HIPAA), which of the following actions by a medical scribe is a
direct violation of patient privacy?
• A. Reviewing the chart of a patient assigned to your supervising
physician
• B. Accessing the medical record of a famous celebrity out of
personal curiosity
• C. Discussing de-identified clinical workflow statistics during a
team training meeting
• D. Documenting vital signs called out by a nurse into the EHR
Correct Answer: B. Accessing the medical record of a famous celebrity
out of personal curiosity
