BIO391 ScribeAmerica Final – 300+ Questions | SOAP Notes, Clinical Documentation, E&M Billing & Physical Exam | ScribeAmerica

This document is a highly comprehensive and exam-ready final review resource for BIO391 ScribeAmerica Courses 1–6, containing over 300 verified questions and answers aligned with the 2025/2026 curriculum. It is designed to fully prepare students for final exams, certification-style assessments, and real-world clinical documentation by covering the complete outpatient clinical workflow from patient intake to billing and follow-up. The material provides in-depth instruction on SOAP note structure, clearly distinguishing subjective versus objective data, and detailing best practices for writing the HPI, ROS, physical exam, assessment, and plan. It thoroughly explains medical decision-making, clinic flow, meaningful use requirements, new versus established patient visits, diagnostic versus health maintenance encounters, and proper documentation standards required for legal, clinical, and reimbursement accuracy. A major strength of this document is its extensive coverage of medical terminology, abbreviations, and clinical shorthand used in outpatient settings. It includes detailed explanations of past medical history (PMHx), past surgical history (PSHx), family history (FHx), and social history (SHx), along with translations of common patient language into proper medical documentation. Normal and abnormal physical exam findings are systematically outlined across all body systems, including cardiovascular, pulmonary, abdominal, neurological, musculoskeletal, pediatric, and dermatological exams. In addition, the document offers robust coverage of chronic disease management and clinical reasoning, with focused sections on hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, asthma, and comorbid conditions. It explains risk factors, chief complaints, diagnostic criteria, non-pharmacological and pharmacological treatments, and follow-up planning. Evaluation and Management (E&M) billing levels, reimbursable versus non-reimbursable terminology, and documentation requirements for insurance reimbursement are also clearly addressed, making this resource particularly valuable for clinical accuracy and professional readiness. This resource is ideal for undergraduate and post-baccalaureate students enrolled in Medical Scribe programs, ScribeAmerica training courses, Health Sciences, Pre-Med, Pre-PA, Pre-Nursing, Allied Health, or Clinical Documentation programs. It is especially useful for students preparing for comprehensive finals, scribe certification exams, outpatient clinical placements, and anyone seeking a single, all-inclusive reference for medical charting, clinical terminology, and outpatient workflow mastery. Keywords: SOAP notes, medical scribe final exam, clinical documentation, HPI writing, physical exam findings, medical terminology, outpatient clinic workflow, E&M billing, reimbursement documentation, meaningful use, chronic disease management, hypertension, diabetes mellitus, hyperlipidemia, medical abbreviations, clinical charting, ScribeAmerica, BIO391