Scribe America Exam | Complete Exam Questions with Verified
Correct Answers and Detailed Explanations – Latest Update
2026/2027 | Graded A+
Question 1
The primary responsibility of a medical scribe is to:
A. Diagnose patients and prescribe medications
B. Document the healthcare provider’s patient encounters accurately
C. Perform surgical procedures
D. Make independent medical decisions
Correct Answer: B. Document the healthcare provider’s patient
encounters accurately
Explanation:
A medical scribe assists healthcare providers by documenting patient visits in
the electronic health record (EHR). The scribe records the history, physical
examination findings, medical decision-making, procedures, and treatment
plans as directed by the provider. Scribes do not diagnose, treat, or make
independent clinical decisions.
Question 2
A medical scribe should always remember that:
A. The physician’s medical judgment cannot be replaced by the scribe
B. The scribe can modify diagnoses when needed
C. The scribe can prescribe medications
D. The scribe is responsible for patient treatment decisions
Correct Answer: A. The physician’s medical judgment cannot be replaced
by the scribe
Explanation:
The medical provider remains responsible for all clinical decisions. A scribe
1|Page
,provides documentation support but does not interpret medical information
independently, diagnose conditions, or create treatment plans.
Question 3
The Electronic Health Record (EHR) is primarily used to:
A. Store and manage patient medical information electronically
B. Replace healthcare providers
C. Perform laboratory testing
D. Control hospital equipment
Correct Answer: A. Store and manage patient medical information
electronically
Explanation:
The EHR contains important patient information including medical history,
examination findings, medications, diagnoses, test results, and treatment
plans. Accurate documentation in the EHR supports communication among
healthcare professionals and improves patient care.
Question 4
Patient confidentiality requires a medical scribe to:
A. Protect patient information from unauthorized access
B. Share patient details with friends
C. Discuss cases publicly
D. Post patient information online
Correct Answer: A. Protect patient information from unauthorized
access
Explanation:
Medical scribes must follow privacy regulations such as HIPAA. Patient
information must only be accessed and discussed for legitimate healthcare
2|Page
,purposes. Unauthorized disclosure can result in legal consequences and loss
of patient trust.
Question 5
HIPAA is a law designed to:
A. Protect the privacy and security of patient health information
B. Control medical school admissions
C. Train healthcare workers
D. Regulate hospital construction
Correct Answer: A. Protect the privacy and security of patient health
information
Explanation:
The Health Insurance Portability and Accountability Act (HIPAA) establishes
rules for protecting patient health information. Healthcare workers must
maintain confidentiality and only access information necessary for their role.
Question 6
When documenting a patient encounter, a scribe should:
A. Record information accurately as stated by the provider
B. Add personal opinions about the patient
C. Change medical findings
D. Create diagnoses independently
Correct Answer: A. Record information accurately as stated by the
provider
Explanation:
A scribe’s role is accurate documentation. The scribe should capture the
provider’s words and actions without adding personal interpretations,
assumptions, or medical opinions.
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, Question 7
The History of Present Illness (HPI) describes:
A. Details about the patient’s current medical problem
B. The patient’s billing information
C. The provider’s employment history
D. Hospital administrative policies
Correct Answer: A. Details about the patient’s current medical problem
Explanation:
The HPI provides a detailed description of the patient’s current complaint. It
may include symptoms, timing, severity, location, associated symptoms, and
factors that improve or worsen the condition.
Question 8
The chief complaint (CC) is:
A. The main reason the patient seeks medical care
B. The final diagnosis
C. The treatment plan
D. The patient’s insurance information
Correct Answer: A. The main reason the patient seeks medical care
Explanation:
The chief complaint is usually recorded using the patient’s own words and
explains why the patient came to the healthcare facility.
Question 9
ROS in medical documentation stands for:
4|Page
Correct Answers and Detailed Explanations – Latest Update
2026/2027 | Graded A+
Question 1
The primary responsibility of a medical scribe is to:
A. Diagnose patients and prescribe medications
B. Document the healthcare provider’s patient encounters accurately
C. Perform surgical procedures
D. Make independent medical decisions
Correct Answer: B. Document the healthcare provider’s patient
encounters accurately
Explanation:
A medical scribe assists healthcare providers by documenting patient visits in
the electronic health record (EHR). The scribe records the history, physical
examination findings, medical decision-making, procedures, and treatment
plans as directed by the provider. Scribes do not diagnose, treat, or make
independent clinical decisions.
Question 2
A medical scribe should always remember that:
A. The physician’s medical judgment cannot be replaced by the scribe
B. The scribe can modify diagnoses when needed
C. The scribe can prescribe medications
D. The scribe is responsible for patient treatment decisions
Correct Answer: A. The physician’s medical judgment cannot be replaced
by the scribe
Explanation:
The medical provider remains responsible for all clinical decisions. A scribe
1|Page
,provides documentation support but does not interpret medical information
independently, diagnose conditions, or create treatment plans.
Question 3
The Electronic Health Record (EHR) is primarily used to:
A. Store and manage patient medical information electronically
B. Replace healthcare providers
C. Perform laboratory testing
D. Control hospital equipment
Correct Answer: A. Store and manage patient medical information
electronically
Explanation:
The EHR contains important patient information including medical history,
examination findings, medications, diagnoses, test results, and treatment
plans. Accurate documentation in the EHR supports communication among
healthcare professionals and improves patient care.
Question 4
Patient confidentiality requires a medical scribe to:
A. Protect patient information from unauthorized access
B. Share patient details with friends
C. Discuss cases publicly
D. Post patient information online
Correct Answer: A. Protect patient information from unauthorized
access
Explanation:
Medical scribes must follow privacy regulations such as HIPAA. Patient
information must only be accessed and discussed for legitimate healthcare
2|Page
,purposes. Unauthorized disclosure can result in legal consequences and loss
of patient trust.
Question 5
HIPAA is a law designed to:
A. Protect the privacy and security of patient health information
B. Control medical school admissions
C. Train healthcare workers
D. Regulate hospital construction
Correct Answer: A. Protect the privacy and security of patient health
information
Explanation:
The Health Insurance Portability and Accountability Act (HIPAA) establishes
rules for protecting patient health information. Healthcare workers must
maintain confidentiality and only access information necessary for their role.
Question 6
When documenting a patient encounter, a scribe should:
A. Record information accurately as stated by the provider
B. Add personal opinions about the patient
C. Change medical findings
D. Create diagnoses independently
Correct Answer: A. Record information accurately as stated by the
provider
Explanation:
A scribe’s role is accurate documentation. The scribe should capture the
provider’s words and actions without adding personal interpretations,
assumptions, or medical opinions.
3|Page
, Question 7
The History of Present Illness (HPI) describes:
A. Details about the patient’s current medical problem
B. The patient’s billing information
C. The provider’s employment history
D. Hospital administrative policies
Correct Answer: A. Details about the patient’s current medical problem
Explanation:
The HPI provides a detailed description of the patient’s current complaint. It
may include symptoms, timing, severity, location, associated symptoms, and
factors that improve or worsen the condition.
Question 8
The chief complaint (CC) is:
A. The main reason the patient seeks medical care
B. The final diagnosis
C. The treatment plan
D. The patient’s insurance information
Correct Answer: A. The main reason the patient seeks medical care
Explanation:
The chief complaint is usually recorded using the patient’s own words and
explains why the patient came to the healthcare facility.
Question 9
ROS in medical documentation stands for:
4|Page
