Scribe Exam Questions and Answers
100% Pass
surgical removal of the gallbladder - ✔✔cholecystectomy
PHI stands for - ✔✔Protected Health Information
T/F sharing info about a case with family is allowed as long as you are scribing with the
physician assigned to the case - ✔✔False
Pt underwent brain surgery to treat bleeding in the brain from a stroke. What is the
PSHx you would record? - ✔✔craniotomy
term for likely course or outcome of a disease - ✔✔prognosis
"what medical problems do you have" is charted where? - ✔✔PHx
Pt who presented for hyperlipidemia mngmt. In middle of visit complains of UT
problems. Which HPI structure would best fit? - ✔✔Multiple complains structure
What are not the purposes of HITECH? - ✔✔To require govn. accountability on health
insurance plans available in the market place. To require patient accountability in
Emily Charlene, All Rights Reserved © 2025 1
, paying for their health care visit. To require equal access, opportunity, and affordability
for health insurance planes by screening pt health information.
Medical term for pt with a h/o infection or inflammation of the liver - ✔✔hepatitis
You're writing an HPI for a complex pt with multiple recent hospital visits for lung
cancer. The HPI structure would be? - ✔✔Chronological structure
Which of the following would be valid complications for CAD? - ✔✔MI
Does this meet level 4 billing?
57 y/o male pt presented with RLQ abd pain that began 5 days ago. He states he was
mowing the lawn when pain began. Pt repots he took OTC tylenol yesterday w/o relief.
There is no N/V/D. - ✔✔no
HIPAA stands for - ✔✔Health Insurance Portability and Accountability Act
What chronic condition requires diagnosis through HbA1c? - ✔✔diabetes mellitus
what is documented in the objective part of the SOAP note? - ✔✔PE, Orders,
interpretations/results, treatments
what condition describes "blood clot in the lungs" - ✔✔Pulmonary embolism (PE)
Emily Charlene, All Rights Reserved © 2025 2
100% Pass
surgical removal of the gallbladder - ✔✔cholecystectomy
PHI stands for - ✔✔Protected Health Information
T/F sharing info about a case with family is allowed as long as you are scribing with the
physician assigned to the case - ✔✔False
Pt underwent brain surgery to treat bleeding in the brain from a stroke. What is the
PSHx you would record? - ✔✔craniotomy
term for likely course or outcome of a disease - ✔✔prognosis
"what medical problems do you have" is charted where? - ✔✔PHx
Pt who presented for hyperlipidemia mngmt. In middle of visit complains of UT
problems. Which HPI structure would best fit? - ✔✔Multiple complains structure
What are not the purposes of HITECH? - ✔✔To require govn. accountability on health
insurance plans available in the market place. To require patient accountability in
Emily Charlene, All Rights Reserved © 2025 1
, paying for their health care visit. To require equal access, opportunity, and affordability
for health insurance planes by screening pt health information.
Medical term for pt with a h/o infection or inflammation of the liver - ✔✔hepatitis
You're writing an HPI for a complex pt with multiple recent hospital visits for lung
cancer. The HPI structure would be? - ✔✔Chronological structure
Which of the following would be valid complications for CAD? - ✔✔MI
Does this meet level 4 billing?
57 y/o male pt presented with RLQ abd pain that began 5 days ago. He states he was
mowing the lawn when pain began. Pt repots he took OTC tylenol yesterday w/o relief.
There is no N/V/D. - ✔✔no
HIPAA stands for - ✔✔Health Insurance Portability and Accountability Act
What chronic condition requires diagnosis through HbA1c? - ✔✔diabetes mellitus
what is documented in the objective part of the SOAP note? - ✔✔PE, Orders,
interpretations/results, treatments
what condition describes "blood clot in the lungs" - ✔✔Pulmonary embolism (PE)
Emily Charlene, All Rights Reserved © 2025 2
