SCRIBEAMERICA OUTPATIENT FINAL EXAM WITH
QUESTIONS AND ANSWERS (VERIFIED ANSWERS GRADED
A+) LATEST 2024/2025
What does "PHI" stand for? Expand the abbreviation - CORRECT ANSWER
protected health information
What medical term describes the surgical removal of the gallbladder? -
CORRECT ANSWER cholecystectomy
T/F. Sharing information about a case with family is allowed, as long as you are
scribing with the physician assigned to the case - CORRECT ANSWER False
A patient's PCP is on vacation. The patient is scheduling to see the NP who is
covering for the PCP during this time. The patient has never been seen by the NP
before. Is the patient considered a new patient or an established patient? -
CORRECT ANSWER Established
What is the medical abbreviation for the condition commonly described as "reflux"
- CORRECT ANSWER GERD
What medical term would best describe "the likely course or outcome of a
disease?" - CORRECT ANSWER prognosis
Which section of the chart should you document when you hear the following cue
"what medical problems do you have?" - CORRECT ANSWER PHx
,You are writing an HPI for a patient who presented for hyperlipidemia
management. In the middle of the visit, your patient also reports having recently
experienced urinary symptoms. Which HPI structure would be the best to use in
this scenario? - CORRECT ANSWER multiple complaints structure
You are writing an HPI for a very complex patient who has had multiple recent
hospital admissions for lung cancer. Which HPI structure would be the best to use
in this scenario? - CORRECT ANSWER chronological structure
Which of the following would be valid complications for CAD? (Select all that
apply) - CORRECT ANSWER MI
11. What are the possible consequences of a HIPAA violation? (Select all that
apply) - CORRECT ANSWER *termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. - CORRECT ANSWER
Health Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose
level or HbA1c? Two words, expand the abbreviation. - CORRECT ANSWER
diabetes mellitus
A patient states she has had a productive cough for 4 days, and yesterday she
developed a fever. Would her fever be considered an associated symptom for her
,productive cough? Why or why not? - CORRECT ANSWER Yes, because the
fever started soon after the cough
15. Which of the following would be documented in the Objective section of the
SOAP note? (select all that apply) - CORRECT ANSWER *Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to__________. (select the best option) -
CORRECT ANSWER maintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood clot in the
lungs"? (Use the abbreviation form of the condition) - CORRECT ANSWER PE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. - CORRECT ANSWER HLD
Which of the following are considered non-reimbursable chief complaints? (Select
all that apply) - CORRECT ANSWER *follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork and
does not know what medications he should be taking at home. He asks you to look
up his medical record when you go to your shift today, giving you verbal
permission to access his information. In this scenario, it is justifiable for you to use
your EMR login to look up the important patient information. - CORRECT
ANSWER False
, A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic
condition should be included in their diagnosis today? Expand the abbreviation? -
CORRECT ANSWER coronary artery disease
A patient states that he has been having abdominal pain for the last three days, and
it varies between mild and severe. Which of the following would best describe the
Timing? - CORRECT ANSWER Waxing and waning
The patient reports a tenderness in their right upper abdomen that began 2 weeks
ago. Based on that information, do you document RUQ tenderness under the
physical exam? - CORRECT ANSWER No
What condition correctly describes "heart attack"? Use the abbreviated form of the
condition. - CORRECT ANSWER MI
A patient reportedly had their tonsils removed as a child. What PSHx would you
record into the chart? - CORRECT ANSWER tonsillectomy
What is the medical term for an elevated heart rate (over 100 beats per minute)? -
CORRECT ANSWER tachycardia
27. Identify what details are included in the following Assessment. (Select all that
apply.)
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute
exacerbation today. He reports decreased urinary output that has progressively
worsened since onset 5 days ago. Creatinine and BUN elevated and worsening
compared to last visit 3 weeks ago. Patient recommended emergency dialysis today
and warned that he may be at risk for death and other complications if he does not
QUESTIONS AND ANSWERS (VERIFIED ANSWERS GRADED
A+) LATEST 2024/2025
What does "PHI" stand for? Expand the abbreviation - CORRECT ANSWER
protected health information
What medical term describes the surgical removal of the gallbladder? -
CORRECT ANSWER cholecystectomy
T/F. Sharing information about a case with family is allowed, as long as you are
scribing with the physician assigned to the case - CORRECT ANSWER False
A patient's PCP is on vacation. The patient is scheduling to see the NP who is
covering for the PCP during this time. The patient has never been seen by the NP
before. Is the patient considered a new patient or an established patient? -
CORRECT ANSWER Established
What is the medical abbreviation for the condition commonly described as "reflux"
- CORRECT ANSWER GERD
What medical term would best describe "the likely course or outcome of a
disease?" - CORRECT ANSWER prognosis
Which section of the chart should you document when you hear the following cue
"what medical problems do you have?" - CORRECT ANSWER PHx
,You are writing an HPI for a patient who presented for hyperlipidemia
management. In the middle of the visit, your patient also reports having recently
experienced urinary symptoms. Which HPI structure would be the best to use in
this scenario? - CORRECT ANSWER multiple complaints structure
You are writing an HPI for a very complex patient who has had multiple recent
hospital admissions for lung cancer. Which HPI structure would be the best to use
in this scenario? - CORRECT ANSWER chronological structure
Which of the following would be valid complications for CAD? (Select all that
apply) - CORRECT ANSWER MI
11. What are the possible consequences of a HIPAA violation? (Select all that
apply) - CORRECT ANSWER *termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. - CORRECT ANSWER
Health Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose
level or HbA1c? Two words, expand the abbreviation. - CORRECT ANSWER
diabetes mellitus
A patient states she has had a productive cough for 4 days, and yesterday she
developed a fever. Would her fever be considered an associated symptom for her
,productive cough? Why or why not? - CORRECT ANSWER Yes, because the
fever started soon after the cough
15. Which of the following would be documented in the Objective section of the
SOAP note? (select all that apply) - CORRECT ANSWER *Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to__________. (select the best option) -
CORRECT ANSWER maintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood clot in the
lungs"? (Use the abbreviation form of the condition) - CORRECT ANSWER PE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. - CORRECT ANSWER HLD
Which of the following are considered non-reimbursable chief complaints? (Select
all that apply) - CORRECT ANSWER *follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork and
does not know what medications he should be taking at home. He asks you to look
up his medical record when you go to your shift today, giving you verbal
permission to access his information. In this scenario, it is justifiable for you to use
your EMR login to look up the important patient information. - CORRECT
ANSWER False
, A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic
condition should be included in their diagnosis today? Expand the abbreviation? -
CORRECT ANSWER coronary artery disease
A patient states that he has been having abdominal pain for the last three days, and
it varies between mild and severe. Which of the following would best describe the
Timing? - CORRECT ANSWER Waxing and waning
The patient reports a tenderness in their right upper abdomen that began 2 weeks
ago. Based on that information, do you document RUQ tenderness under the
physical exam? - CORRECT ANSWER No
What condition correctly describes "heart attack"? Use the abbreviated form of the
condition. - CORRECT ANSWER MI
A patient reportedly had their tonsils removed as a child. What PSHx would you
record into the chart? - CORRECT ANSWER tonsillectomy
What is the medical term for an elevated heart rate (over 100 beats per minute)? -
CORRECT ANSWER tachycardia
27. Identify what details are included in the following Assessment. (Select all that
apply.)
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute
exacerbation today. He reports decreased urinary output that has progressively
worsened since onset 5 days ago. Creatinine and BUN elevated and worsening
compared to last visit 3 weeks ago. Patient recommended emergency dialysis today
and warned that he may be at risk for death and other complications if he does not
