PRACTICE QUESTIONS AND STUDY GUIDE ACCURATE
EXAM COMPLETE A
Question 1: Which component of the SOAP note contains the patient's chief complaint and the
narrative of the present illness?
A) Objective
B) Assessment
C) Plan
D) Subjective
Correct Answer: D
Rationale: The Subjective section records the patient's own words (chief complaint) and the
History of Present Illness (HPI). This section captures what the patient reports, including
symptoms, concerns, and the chronological narrative of their current problem.
Question 2: What does HIPAA stand for?
A) Health Insurance Plan and Accountability Act
B) Health Information Privacy and Authorization Act
C) Health Insurance Portability and Accountability Act
D) Hospital Information Privacy Act
Correct Answer: C
Rationale: HIPAA is the Health Insurance Portability and Accountability Act, a federal law that
establishes national standards for protecting sensitive patient health information from being
disclosed without the patient's consent or knowledge.
Question 3: What is the primary function of a medical scribe?
A) Perform physical examinations on patients
B) Create the medical note (documentation) in real-time
C) Diagnose diseases and conditions
D) Prescribe medications for patients
Correct Answer: B
Rationale: The primary function of a medical scribe is to create the medical note
(documentation) in real-time as the physician evaluates the patient. Scribes do not perform
,examinations, diagnose, or prescribe; they document the physician's findings and patient
history to improve efficiency and accuracy.
Question 4: The abbreviation "RLQ" stands for:
A) Right lung quadrant
B) Right lower quadrant
C) Renal lower quadrant
D) Rectal lower quadrant
Correct Answer: B
Rationale: RLQ is the standard abbreviation for the right lower quadrant of the abdomen, which
contains the appendix.
Question 5: Which suffix denotes surgical removal of a body part?
A) -plasty
B) -ostomy
C) -otomy
D) -ectomy
Correct Answer: D
Rationale: The suffix "-ectomy" means excision or surgical removal of a body part. For example,
appendectomy is the surgical removal of the appendix.
Question 6: The root "nephr-" refers to which organ?
A) Liver
B) Kidney
C) Heart
D) Lung
Correct Answer: B
Rationale: "Nephr-" is derived from Greek and refers to the kidney. Nephrology is the branch of
medicine dealing with kidney function and disease.
Question 7: Which of the following is considered Protected Health Information (PHI) under
HIPAA?
A) The hospital's address
B) A patient's social security number
C) The physician's name
D) The hospital's phone number
,Correct Answer: B
Rationale: Protected Health Information (PHI) includes any individually identifiable health
information, such as names, dates of birth, social security numbers, medical records, and any
other information that could be used to identify a patient.
Question 8: In anatomical position, the palms face:
A) Posteriorly
B) Medially
C) Anteriorly
D) Laterally
Correct Answer: C
Rationale: Standard anatomical position has the body standing upright, feet together, arms at
the sides, and palms facing forward (anteriorly).
Question 9: The term "hematuria" refers to:
A) Blood in the stool
B) Blood in the urine
C) Blood in the sputum
D) Blood in the vomit
Correct Answer: B
Rationale: Hematuria is the presence of blood in the urine. The prefix "hem-" refers to blood,
and "-uria" refers to urine.
Question 10: Which mnemonic framework is most commonly used to structure the History of
Present Illness (HPI)?
A) SBAR
B) OLDCARTS
C) HEADSS
D) CAGE
Correct Answer: B
Rationale: OLDCARTS stands for Onset, Location, Duration, Character, Aggravating factors,
Relieving factors, Timing, and Severity. This framework is the standard for HPI documentation.
Question 11: The "3-year rule" in billing primarily determines:
A) Whether a patient is considered new or established for coding purposes
B) The maximum number of visits per year covered by insurance
, C) The interval for routine preventive screenings
D) The duration a scribe can stay in a clinical setting
Correct Answer: A
Rationale: A patient is considered "new" for billing purposes if they have not been seen by the
same physician or practice within the past three years for the same specialty.
Question 12: What does the abbreviation "SOB" stand for?
A) Slurred oral breathing
B) Shortness of breath
C) Syncope on bed
D) Severe obstructive bronchitis
Correct Answer: B
Rationale: In clinical shorthand, SOB stands for shortness of breath, a common symptom
reported by patients with respiratory or cardiac conditions.
Question 13: The LUQ (left upper quadrant) of the abdomen contains which organs?
A) Liver and gallbladder
B) Appendix and cecum
C) Stomach and spleen
D) Sigmoid colon
Correct Answer: C
Rationale: The left upper quadrant (LUQ) contains the stomach and spleen. The liver and
gallbladder are in the RUQ, the appendix is in the RLQ, and the sigmoid colon is in the LLQ.
Question 14: In the physician-scribe relationship, the scribe is allowed to:
A) Perform a physical examination on the patient
B) Document in real time while the physician sees the patient
C) Make medication changes without physician approval
D) Discuss the case with other clinicians without the physician present
Correct Answer: B
Rationale: Scribes document in real time but do not engage in clinical decision-making, perform
examinations, make medication changes, or discuss cases independently. Their role is strictly
documentation.
Question 15: The term "pruritus" describes: