ScribeAmerica Outpatient Course 1
Exam Questions with Verified Answers
(100% Pass)
Subjective vs. objective: - Answer- Feeling vs. fact
Pain vs. tenderness - Answer- Patient's feeling vs. physician's assessment
Benign - Answer- Normal, nothing of concern
Acute - Answer- New onset, likely concerning
Chronic - Answer- Long-standing, not of direct concern
Baseline - Answer- An individual's normal state of being
Auscultation - Answer- Listening with a stethoscope
Palpation - Answer- The act of pressing on an area (by the physician)
Inpatient - Answer- Admitted to the hospital overnight
Outpatient - Answer- Seen and sent home the same day
Chief complaint - Answer- The main reason for the patient's visit
Mid-Level Provider - Answer- Nurse Practitioner (LNP) or Physician Assistant (PA) that
works under the supervision of a physician to diagnose and treat patients
Medical provider - Answer- Mid-level provider that diagnoses and treats patients
Nurse or Medical Assistant - Answer- Records medical histories and symptoms,
monitors the patient, completes the meaningful use requirements, administers
medications, assists with procedures
Clinical provider - Answer- Includes both the mid-level provider and nurse or medical
assistant that are direct patient care
Scribe - Answer- Documents the patient's visit on behalf of the physician
Clerical - Answer- Receptionist and scribe that there is no patient care and only
documentation
, Scribes CAN.... - Answer- -Document the history, physical exam, results, procedures,
assessment, and plan
-Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
Assessment vs Plan - Answer- Diagnosis vs Treatment
Scribes CANNOT... - Answer- -Partake in any activity that may affect patient health or
outcome
-Touch patients
-Handle bodily fluids or specimens
-Sign or authenticate any chart or record
-Give verbal orders or submit electronic orders
-NO direct patient care, No patient samples, No using logins other than your own
NEW Patient - Answer- No previous records, Longer visit, and Detailed chart
ESTABLISHED Patient - Answer- Previous records available, Shorter visit, and Concise
chart
Diagnostic Visit - Answer- New problem, Chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
Health Management Visit - Answer- 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
CLINIC FLOW - Answer- Check in -> Physical evaluation -> Orders & Results ->
Assessment & Plan -> Check Out
CLINIC FLOW - CHECK-IN - Answer- Patient Walks in (Diagnostic vs. Health
Management) -> Room Placement -> Meaningful Use obtained by Nurse/MA (Chief
complaint, Vital signs: HR, BP, T, RR), Height, Weight, BMI, Smoking Status) ->
Nurse/MA Assessment (Confirm chief complaints, review allergies/medications , brief
past medical history)
CLINIC FLOW - PHYSICIAN EVAL - Answer- Review the patient's medical records
(Assessment & plan from the previous visit, Labs and/or imaging results) -> History and
Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical
Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the
symptoms)
CLINIC FLOW - ORDERS & RESULTS - Answer- Orders (Laboratory studies, Imaging
studies, and Procedures) -> Results (May result during visit (rare) or in a few days)
Exam Questions with Verified Answers
(100% Pass)
Subjective vs. objective: - Answer- Feeling vs. fact
Pain vs. tenderness - Answer- Patient's feeling vs. physician's assessment
Benign - Answer- Normal, nothing of concern
Acute - Answer- New onset, likely concerning
Chronic - Answer- Long-standing, not of direct concern
Baseline - Answer- An individual's normal state of being
Auscultation - Answer- Listening with a stethoscope
Palpation - Answer- The act of pressing on an area (by the physician)
Inpatient - Answer- Admitted to the hospital overnight
Outpatient - Answer- Seen and sent home the same day
Chief complaint - Answer- The main reason for the patient's visit
Mid-Level Provider - Answer- Nurse Practitioner (LNP) or Physician Assistant (PA) that
works under the supervision of a physician to diagnose and treat patients
Medical provider - Answer- Mid-level provider that diagnoses and treats patients
Nurse or Medical Assistant - Answer- Records medical histories and symptoms,
monitors the patient, completes the meaningful use requirements, administers
medications, assists with procedures
Clinical provider - Answer- Includes both the mid-level provider and nurse or medical
assistant that are direct patient care
Scribe - Answer- Documents the patient's visit on behalf of the physician
Clerical - Answer- Receptionist and scribe that there is no patient care and only
documentation
, Scribes CAN.... - Answer- -Document the history, physical exam, results, procedures,
assessment, and plan
-Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
Assessment vs Plan - Answer- Diagnosis vs Treatment
Scribes CANNOT... - Answer- -Partake in any activity that may affect patient health or
outcome
-Touch patients
-Handle bodily fluids or specimens
-Sign or authenticate any chart or record
-Give verbal orders or submit electronic orders
-NO direct patient care, No patient samples, No using logins other than your own
NEW Patient - Answer- No previous records, Longer visit, and Detailed chart
ESTABLISHED Patient - Answer- Previous records available, Shorter visit, and Concise
chart
Diagnostic Visit - Answer- New problem, Chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
Health Management Visit - Answer- 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
CLINIC FLOW - Answer- Check in -> Physical evaluation -> Orders & Results ->
Assessment & Plan -> Check Out
CLINIC FLOW - CHECK-IN - Answer- Patient Walks in (Diagnostic vs. Health
Management) -> Room Placement -> Meaningful Use obtained by Nurse/MA (Chief
complaint, Vital signs: HR, BP, T, RR), Height, Weight, BMI, Smoking Status) ->
Nurse/MA Assessment (Confirm chief complaints, review allergies/medications , brief
past medical history)
CLINIC FLOW - PHYSICIAN EVAL - Answer- Review the patient's medical records
(Assessment & plan from the previous visit, Labs and/or imaging results) -> History and
Physical H&P (HPI History of Present Illness, ROS Review of Systems, PE Physical
Exam) -> Differential Dx ONLY for diagnostic visit (Possible Dx that may be causing the
symptoms)
CLINIC FLOW - ORDERS & RESULTS - Answer- Orders (Laboratory studies, Imaging
studies, and Procedures) -> Results (May result during visit (rare) or in a few days)
