Scribe OP final exam Questions and
Answers 100% Pass
subjective vs objective - ✔✔feeling vs. fact
pain vs tenderness - ✔✔patient's feeling vs. physician's assessment
benign - ✔✔Normal, nothing of concern
acute vs chronic - ✔✔new onset vs long standing
baseline - ✔✔An individual's normal state of being
Auscultation - ✔✔Listening with a stethoscope
Emily Charlene, All Rights Reserved © 2025 1
,Palpation - ✔✔The act of pressing on an area (by the physician)
inpatient - ✔✔Admitted to the hospital overnight
outpatient - ✔✔seen and sent home the same day
chief complaint - ✔✔the main reason for the patient's visit
meaningful use - ✔✔a set of government mandated criteria that must be obtained for
every patient
medical decision making - ✔✔the physician's thought process
give two examples of mid-level providers - ✔✔LPN, PA
what tasks can you complete as a scribe:
Emily Charlene, All Rights Reserved © 2025 2
,-document the history and physical exam while the physician performs them
-help a patient from his wheelchair to the exam chair
-locate previous results to show the provider
-sign the doctor's charts at the end of the day - ✔✔-document the history and physical
exam while the physician performs them
-locate previous results to show the provider
a chart for an established patient will be________ than the chart for a new patient -
✔✔longer
in a diagnostic visit, the patient has a ________ complaint - ✔✔new
who typically obtains meaningful use requirements during patient check-in? -
✔✔MA/nurse
Emily Charlene, All Rights Reserved © 2025 3
, H&P stands for _____ & ______ and is part of the ________ evaluation - ✔✔history &
physical, provider
name two items you will include in the patient's plan - ✔✔medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? -
✔✔physical exam
"I have high blood pressure" --> you would write.... - ✔✔HTN
"I take shots for my diabetes" --> you would write.... - ✔✔IDDM
"My doctor says my heart is failing." --> you would write.... - ✔✔CHF
"I have acid reflux" --> you would write.... - ✔✔GERD
Emily Charlene, All Rights Reserved © 2025 4
Answers 100% Pass
subjective vs objective - ✔✔feeling vs. fact
pain vs tenderness - ✔✔patient's feeling vs. physician's assessment
benign - ✔✔Normal, nothing of concern
acute vs chronic - ✔✔new onset vs long standing
baseline - ✔✔An individual's normal state of being
Auscultation - ✔✔Listening with a stethoscope
Emily Charlene, All Rights Reserved © 2025 1
,Palpation - ✔✔The act of pressing on an area (by the physician)
inpatient - ✔✔Admitted to the hospital overnight
outpatient - ✔✔seen and sent home the same day
chief complaint - ✔✔the main reason for the patient's visit
meaningful use - ✔✔a set of government mandated criteria that must be obtained for
every patient
medical decision making - ✔✔the physician's thought process
give two examples of mid-level providers - ✔✔LPN, PA
what tasks can you complete as a scribe:
Emily Charlene, All Rights Reserved © 2025 2
,-document the history and physical exam while the physician performs them
-help a patient from his wheelchair to the exam chair
-locate previous results to show the provider
-sign the doctor's charts at the end of the day - ✔✔-document the history and physical
exam while the physician performs them
-locate previous results to show the provider
a chart for an established patient will be________ than the chart for a new patient -
✔✔longer
in a diagnostic visit, the patient has a ________ complaint - ✔✔new
who typically obtains meaningful use requirements during patient check-in? -
✔✔MA/nurse
Emily Charlene, All Rights Reserved © 2025 3
, H&P stands for _____ & ______ and is part of the ________ evaluation - ✔✔history &
physical, provider
name two items you will include in the patient's plan - ✔✔medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? -
✔✔physical exam
"I have high blood pressure" --> you would write.... - ✔✔HTN
"I take shots for my diabetes" --> you would write.... - ✔✔IDDM
"My doctor says my heart is failing." --> you would write.... - ✔✔CHF
"I have acid reflux" --> you would write.... - ✔✔GERD
Emily Charlene, All Rights Reserved © 2025 4
