1
scribeamerica Outpatient Final exam
Questions and Correct Answers
What does "PHI" stand for? Expand the abbreviation
Answer: protected health information
What medical term describes the surgical removal of
the gallbladder? 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 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? Answer: Established
What is the medical abbreviation for the condition
commonly described as "reflux" Answer: GERD
What medical term would best describe "the likely
course or outcome of a disease?" Answer: prognosis
Pretest - Stuvia US
,2
Which section of the chart should you document when
you hear the following cue "what medical problems do
you have?" 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? 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? Answer: chronological structure
Which of the following would be valid complications for
CAD? (Select all that apply) Answer: MI
11. What are the possible consequences of a HIPAA
violation? (Select all that apply) Answer: *termination
*monetary fines to you and the hospital
*prison time
Pretest - Stuvia US
, 3
*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.
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. 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? 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) Answer: *Orders
Pretest - Stuvia US
scribeamerica Outpatient Final exam
Questions and Correct Answers
What does "PHI" stand for? Expand the abbreviation
Answer: protected health information
What medical term describes the surgical removal of
the gallbladder? 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 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? Answer: Established
What is the medical abbreviation for the condition
commonly described as "reflux" Answer: GERD
What medical term would best describe "the likely
course or outcome of a disease?" Answer: prognosis
Pretest - Stuvia US
,2
Which section of the chart should you document when
you hear the following cue "what medical problems do
you have?" 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? 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? Answer: chronological structure
Which of the following would be valid complications for
CAD? (Select all that apply) Answer: MI
11. What are the possible consequences of a HIPAA
violation? (Select all that apply) Answer: *termination
*monetary fines to you and the hospital
*prison time
Pretest - Stuvia US
, 3
*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.
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. 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? 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) Answer: *Orders
Pretest - Stuvia US
