BIO391 OP Course 4 – 120 Questions | Objective Documentation, Physical Exams & Vital Signs | ScribeAmerica

This document is a comprehensive and exam-focused study guide for BIO391 ScribeAmerica Outpatient Course 4, containing approximately 120 verified questions and answers dedicated to the Objective component of medical documentation. It is specifically designed to help students master accurate, compliant, and clinically sound objective charting used in outpatient, urgent care, and internal medicine settings. The material provides detailed coverage of all elements of the Objective section, including vital signs, physical exam findings, and diagnostic orders and results. Normal and abnormal vital sign ranges are clearly defined, with emphasis on blood pressure classification, heart rate, respiratory rate, temperature, and oxygen saturation. The document systematically outlines how to document both abbreviated and complete physical exams, ensuring clarity, consistency, and avoidance of contradictions. Extensive attention is given to physical exam terminology across all body systems. The guide details benign “normal” exam phrasing alongside a wide range of abnormal findings for HEENT, cardiovascular, pulmonary, abdominal, musculoskeletal, skin, neurological, and psychiatric exams. It also covers advanced neurological documentation, including motor strength grading, deep tendon reflexes, cranial nerve testing, cerebellar function, and pediatric-specific exam findings, all presented in a clear exam-oriented format. The document further emphasizes documentation accuracy by teaching how to properly identify and record red-flag findings such as peritoneal signs, abnormal heart rhythms, respiratory distress, focal neurological deficits, skin infections, trauma patterns, and pediatric abnormalities. By pairing correct phrasing with common documentation pitfalls, it prepares students for both exam success and real-world charting expectations. This resource is highly relevant for undergraduate and post-baccalaureate students enrolled in Medical Scribe programs, ScribeAmerica outpatient training courses, Health Sciences, Pre-Med, Pre-PA, Pre-Nursing, Allied Health, or Clinical Documentation programs. It is especially useful for students preparing for outpatient and urgent care practicums, scribe certification exams, and assessments requiring precise objective documentation and physical exam interpretation. Keywords: objective documentation, physical exam findings, vital signs, abnormal exam findings, neurological exam, pediatric physical exam, outpatient charting, diagnostic results, clinical documentation accuracy, medical scribe training, ScribeAmerica, BIO391