BIO391 Final Review – 250+ Questions | SOAP Notes, Billing & Coding, HIPAA & Clinical Documentation | ScribeAmerica

This document is a comprehensive, all-in-one final exam review resource for BIO391 ScribeAmerica (2025/2026), containing 250+ verified exam questions and answers that span the full outpatient scribe curriculum. It integrates material from all ScribeAmerica courses into a single, high-yield study guide designed for cumulative finals, certification-style exams, and real-world clinical readiness. The content provides in-depth coverage of SOAP note documentation, including Subjective (chief complaint, HPI structures, ROS accuracy), Objective (vital signs, normal vs abnormal physical exam findings across all body systems), Assessment (problem lists, diagnostic summaries, prognosis), and Plan (treatments, medications, referrals, follow-up timelines). Clear distinctions are made between simple, brief, and comprehensive assessment structures, with strong emphasis on avoiding contradictions and maintaining billing compliance. A major portion of the document focuses on outpatient billing and coding, explaining Evaluation & Management (E&M) levels, documentation requirements for new versus established patients, time-based counseling rules, and medical decision-making complexity. It thoroughly differentiates ICD-10 diagnosis codes, CPT procedure codes, Z-codes for preventive care, modifiers, and superbill requirements, using realistic exam-style scenarios to reinforce correct billing determination. The guide also delivers extensive instruction on HIPAA, HITECH, MACRA, MIPS, PHI protection, and compliance rules, clearly outlining what scribes may and may not do in clinical settings and the legal consequences of violations. In addition, it includes a large medical terminology and abbreviation section covering common diagnoses, procedures, symptoms, physical exam findings, imaging, labs, medications, and documentation shorthand used daily in outpatient, internal medicine, and urgent care clinics. This resource is ideal for Medical Scribe trainees, ScribeAmerica students, and learners in Health Sciences, Pre-Med, Pre-PA, Pre-Nursing, Allied Health, and Clinical Documentation programs. It is especially valuable for students preparing for cumulative finals, scribe certification exams, onboarding assessments, or clinical practicums, offering a single, structured reference that mirrors both exam expectations and real clinical workflows. Keywords: medical scribe final exam, SOAP notes, clinical documentation, HPI writing, physical exam findings, outpatient billing, E&M levels, ICD-10 codes, CPT codes, HIPAA compliance, medical terminology, clinical abbreviations, medical decision making, ScribeAmerica training, BIO391