ScribeAmerica Outpatient Final: Practice
Questions & Best Graded Answers
What will the scribe document for the outpatient visit? - ANSWER-Important notes for
past medical records
History and Physical
Laboratory and radiology results
Physician Interpretation of XRs and EKGs
Assessment and Plan
Who is the first person to speak with the patient after he/she is placed in the room? -
ANSWER-Nurse or MA
What are the meaningful use requirements the nurse or MA will obtain? - ANSWER-
Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status
What does H&P abbreviate and who performs this evaluation? - ANSWER-History and
Physical, physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER-No, only
for a diagnostic visit
What information will be included in the patient's plan? - ANSWER-Specialist follow-up,
instructions for lifestyle and preventative care, routine follow-up
The CBC shows anemia - ANSWER-Results
The EKG shows NSR - ANSWER-Results
The pt came to the clinic for chest pain - ANSWER-HPI/ROS
The pt also stubbed his toe last week - ANSWER-HPI/ROS
The pt is in no acute distress - ANSWER-Physical Exam
The pt has suffered from HTN for many years - ANSWER-PMHx
Thee is tenderness of the RUQ - ANSWER-PE
The pt's mother has heart disease - ANSWER-FHX
The diagnosis is upper respiratory infection - ANSWER-Assessment
, The pt will be prescribed penicillin today - ANSWER-Plan
What age would a family member's cardiac disease indicate an increased risk for similar
heart disease in the pt? - ANSWER-<55 y/o
What are three common general FHx your physician may ask about? - ANSWER-HTN,
CA, DM
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx
section? - ANSWER-Yes
Why must smoking status be documented on every patient 13 years and older? -
ANSWER-Meaningful use requirements
HIPPA Rule 1 - ANSWER-If a patient is not assigned to your doctor, do not touch the
chart
HIPAA Rule 2 - ANSWER-There is always someone watching
HIPAA Rule 3 - ANSWER-Never share your username or password
HIPAA Rule 4 - ANSWER-Your job does not belong on social media
HIPAA Rule 5 - ANSWER-Ask yourself "Do I need to access this for my job?"
HIPAA Rule 6 - ANSWER-Do not store any protected health information (PHI) on non-
approved systems
HIPAA Rule 7 - ANSWER-do not access family, friend or own medical record
HIPAA Rule 8 - ANSWER-No cell phones or pictures
What should you do before leaving your workstation for the cafeteria? - ANSWER-Log
out
What is the purpose of HIPAA? - ANSWER-It is a body of laws designed to protect the
private health information of patients across the country.
What does PHI stand for? - ANSWER-Protected Health Information
Name three items that are considered PHI - ANSWER-First or Last name, Date of birth,
medical record number, the fact the patient was seen at the clinic
What is the purpose of HITECH? - ANSWER-The Health Information Technology for
Economic and Clinical Health Act addresses the privacy and security issues related to
electronic transmission of health information. PHI may not be transferred electronically,
Questions & Best Graded Answers
What will the scribe document for the outpatient visit? - ANSWER-Important notes for
past medical records
History and Physical
Laboratory and radiology results
Physician Interpretation of XRs and EKGs
Assessment and Plan
Who is the first person to speak with the patient after he/she is placed in the room? -
ANSWER-Nurse or MA
What are the meaningful use requirements the nurse or MA will obtain? - ANSWER-
Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status
What does H&P abbreviate and who performs this evaluation? - ANSWER-History and
Physical, physician
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER-No, only
for a diagnostic visit
What information will be included in the patient's plan? - ANSWER-Specialist follow-up,
instructions for lifestyle and preventative care, routine follow-up
The CBC shows anemia - ANSWER-Results
The EKG shows NSR - ANSWER-Results
The pt came to the clinic for chest pain - ANSWER-HPI/ROS
The pt also stubbed his toe last week - ANSWER-HPI/ROS
The pt is in no acute distress - ANSWER-Physical Exam
The pt has suffered from HTN for many years - ANSWER-PMHx
Thee is tenderness of the RUQ - ANSWER-PE
The pt's mother has heart disease - ANSWER-FHX
The diagnosis is upper respiratory infection - ANSWER-Assessment
, The pt will be prescribed penicillin today - ANSWER-Plan
What age would a family member's cardiac disease indicate an increased risk for similar
heart disease in the pt? - ANSWER-<55 y/o
What are three common general FHx your physician may ask about? - ANSWER-HTN,
CA, DM
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx
section? - ANSWER-Yes
Why must smoking status be documented on every patient 13 years and older? -
ANSWER-Meaningful use requirements
HIPPA Rule 1 - ANSWER-If a patient is not assigned to your doctor, do not touch the
chart
HIPAA Rule 2 - ANSWER-There is always someone watching
HIPAA Rule 3 - ANSWER-Never share your username or password
HIPAA Rule 4 - ANSWER-Your job does not belong on social media
HIPAA Rule 5 - ANSWER-Ask yourself "Do I need to access this for my job?"
HIPAA Rule 6 - ANSWER-Do not store any protected health information (PHI) on non-
approved systems
HIPAA Rule 7 - ANSWER-do not access family, friend or own medical record
HIPAA Rule 8 - ANSWER-No cell phones or pictures
What should you do before leaving your workstation for the cafeteria? - ANSWER-Log
out
What is the purpose of HIPAA? - ANSWER-It is a body of laws designed to protect the
private health information of patients across the country.
What does PHI stand for? - ANSWER-Protected Health Information
Name three items that are considered PHI - ANSWER-First or Last name, Date of birth,
medical record number, the fact the patient was seen at the clinic
What is the purpose of HITECH? - ANSWER-The Health Information Technology for
Economic and Clinical Health Act addresses the privacy and security issues related to
electronic transmission of health information. PHI may not be transferred electronically,
