BIO391 OP Course 5 – 40 Questions | Assessment, Plan, HIPAA & Medical Compliance | ScribeAmerica

This document is a concise yet high-yield exam preparation resource for BIO391 ScribeAmerica Outpatient Course 5, containing approximately 40 clearly structured questions with fully verified answers based on the 2025/2026 curriculum. It focuses on the Assessment and Plan components of the SOAP note, along with essential healthcare compliance, documentation standards, and federal regulations required for safe and legal clinical practice. The content provides a clear breakdown of key clinical documentation concepts, including diagnosis, assessment, plan, prognosis, and follow-up. It explains how to correctly structure assessment summaries (simple, brief, and comprehensive) and how to write effective result and plan summaries that clearly communicate treatments, prescriptions, diagnostic orders, referrals, and follow-up timelines. These sections emphasize accuracy, clarity, and alignment with outpatient documentation and reimbursement expectations. A significant portion of the document is dedicated to healthcare systems, compliance, and legal responsibility. It thoroughly covers MACRA, CMS, MIPS, CPOE, EHR versus EMR distinctions, and the role of electronic documentation in modern clinical workflows. In addition, it provides an in-depth review of HIPAA and HITECH regulations, including protected health information (PHI), access limitations, data security rules, and real-world consequences of violations. The document reinforces professional conduct standards, emphasizing privacy, ethical responsibility, and risk avoidance in clinical environments. This resource is especially 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 particularly useful for students preparing for course exams, compliance assessments, scribe certification evaluations, or those seeking a clear and efficient review of assessment planning and healthcare regulations essential for clinical practice. Keywords: assessment documentation, plan of care, SOAP notes, medical compliance, HIPAA rules, protected health information, HITECH act, MACRA, MIPS, CMS, EHR documentation, EMR systems, clinical workflow, medical scribe training, ScribeAmerica, BIO391