SCRIBE FINAL EXAM QUESTIONS AND
ANSWEERS
"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 seek further urgent medical attention.
Patient understands and agrees to be transferred to the ED."
What details does this include? - Answer-1. Diagnosis
2. Prognosis/Plan
3. Age and sex
4. PHx, if relevant
5. HPI
6. Results
T/F. All symptoms documented in the ROS are also documented in the HPI. - Answer-
False
What is the medical term for "open heart surgery"? - Answer-Coronary Artery Bypass
Graft
T/F. A scribe does NOT need to document a problem list for patients that are young,
healthy, and without any medical problems. - Answer-False
If a patient signs a waiver giving you permission to capture photo of their unique rash,
would you be committing a HIPAA violation by using your cellphone to capture the
photo? - Answer-Yes because the phone is not an approved hospital device and it is not
encrypted.
What condition correctly describes "Narrowing of the coronary arteries limits blood
supply to the heart muscle causing ischemia"? - Answer-CAD
An elderly female patient has a history of brittle bone disease and is at risk for
developing bone fractures. What PMHx would you record into the chart? - Answer-Bone
Fx
Organize the parts of the chart in order from top (1) to bottom (7). - Answer-1. HPI
2. ROS
3. PMHx
4. PE
5. Orders/Results
6. Assessment
, 7. Plan
What ROS system would include dysphagia, the medical term for difficult or painful
swallowing? - Answer-ENT
T/F. The ROS does not contain the CC and its associated symptoms because they are
already listed in the HPI. - Answer-False
T/F. Resolved problems may be deleted from the problem list. - Answer-False
A patient requires a heart bypass to treat a heart attack. What PSHx would you record
into the chart? - Answer-CABG
A female patient has been pregnant four times in the past, is currently pregnant, and
has two children at home. Calculate the G, P and A, respectively. - Answer-5, 2, 2
T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they
are included in the Problem List section. - Answer-False
T/F. It is acceptable to look up your own medical information while working in the clinic.
- Answer-False
What condition correctly describes "mini-stroke"? - Answer-TIA
Which of the following are considered to be cardiac risk factors for CP patients?
(cerebral Palsey) - Answer-Family hx of CAD <55 y/o
HLD
CAD
PSHx of CABG, angioplasty, and stent
HTN
Tobacco use
DM
What is the medical term for "slow heart rate"? - Answer-Bradycardia
What medical term describes the surgical removal of the gallbladder? - Answer-
Cholecystectomy
What does "PHI" stand for? - Answer-Protected Health Information
T/F. Sharing information about a case with family is allowed, as long as you are scribing
with the physician assigned to the case. - Answer-False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - Answer-Craniotomy
ANSWEERS
"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 seek further urgent medical attention.
Patient understands and agrees to be transferred to the ED."
What details does this include? - Answer-1. Diagnosis
2. Prognosis/Plan
3. Age and sex
4. PHx, if relevant
5. HPI
6. Results
T/F. All symptoms documented in the ROS are also documented in the HPI. - Answer-
False
What is the medical term for "open heart surgery"? - Answer-Coronary Artery Bypass
Graft
T/F. A scribe does NOT need to document a problem list for patients that are young,
healthy, and without any medical problems. - Answer-False
If a patient signs a waiver giving you permission to capture photo of their unique rash,
would you be committing a HIPAA violation by using your cellphone to capture the
photo? - Answer-Yes because the phone is not an approved hospital device and it is not
encrypted.
What condition correctly describes "Narrowing of the coronary arteries limits blood
supply to the heart muscle causing ischemia"? - Answer-CAD
An elderly female patient has a history of brittle bone disease and is at risk for
developing bone fractures. What PMHx would you record into the chart? - Answer-Bone
Fx
Organize the parts of the chart in order from top (1) to bottom (7). - Answer-1. HPI
2. ROS
3. PMHx
4. PE
5. Orders/Results
6. Assessment
, 7. Plan
What ROS system would include dysphagia, the medical term for difficult or painful
swallowing? - Answer-ENT
T/F. The ROS does not contain the CC and its associated symptoms because they are
already listed in the HPI. - Answer-False
T/F. Resolved problems may be deleted from the problem list. - Answer-False
A patient requires a heart bypass to treat a heart attack. What PSHx would you record
into the chart? - Answer-CABG
A female patient has been pregnant four times in the past, is currently pregnant, and
has two children at home. Calculate the G, P and A, respectively. - Answer-5, 2, 2
T/F. Active diagnoses do NOT have to be included in the PHx section of the chart if they
are included in the Problem List section. - Answer-False
T/F. It is acceptable to look up your own medical information while working in the clinic.
- Answer-False
What condition correctly describes "mini-stroke"? - Answer-TIA
Which of the following are considered to be cardiac risk factors for CP patients?
(cerebral Palsey) - Answer-Family hx of CAD <55 y/o
HLD
CAD
PSHx of CABG, angioplasty, and stent
HTN
Tobacco use
DM
What is the medical term for "slow heart rate"? - Answer-Bradycardia
What medical term describes the surgical removal of the gallbladder? - Answer-
Cholecystectomy
What does "PHI" stand for? - Answer-Protected Health Information
T/F. Sharing information about a case with family is allowed, as long as you are scribing
with the physician assigned to the case. - Answer-False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - Answer-Craniotomy
