MEDICAL SCRIBE – QUIZZES
QUESTIONS WITH CORRECT ANSWERS
Acute vs Chronic - Answer-new onset, to be of concern vs. long standing, not as
concerning
Seen and sent home the same day - Answer-outpatient
Chief complaint is... - Answer-the main reason for the patient's visit
A set of government mandated criteria that must be obtained for every patient - Answer-
meaningful use
Baseline - Answer-An individual's normal state of being
Tasks you CAN complete as a scribe - Answer-- document the history and physical
exam while the physician performs them
- pend orders upon instruction of the provider
- locate previous results to show provider
Scribes cannot... - Answer--touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
You are working at a facility where the nurse completes the ROS for the patient.
However, when you enter the room with the doctor, you notice that one of the patient's
answers contradicts the ROS recorded by the nurse. What should you do? - Answer-
Wait until you exit the patient room and notify the doctor of the discrepancy
A SOAP note for an established patient will be ________ than the note for a new patient
- Answer-shorter
A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - Answer-A Diagnostic visist
Why is documenting a thorough HPI important? - Answer-HPI serves as the basis for
the work up that follows
Elements of the HPI - Answer-Onset, Timing, Location, Quality, Severity, Modifying
Factors, Associated Sx, Context
, 3 primary methods of structuring an outpatient HPI - Answer-Single Complaint Formula
Multiple Complaint Formula
Chronologic (Complex Story)
Which HPI structure is best to use for a complex patient with multiple co-morbidities and
a recent work-up? - Answer-multiple complaint or chronological
What are four important details to include in the HPI of a patient who has been
evaluated by another healthcare provider for similar symptoms? - Answer-- who the
provider was
- what tests were ordered
- test results
- diagnosis
The majority of diabetes patients have... - Answer-T2DM
What are common symptoms of diabetes? - Answer-glucosuria, polyuria, polydipsia
Which DM can be treated with oral medication? - Answer-Type II
T/F: The structure of the SOAP note closely follows the clinic flow - Answer-T
T/F: You will usually document the assessment before documenting the HPI - Answer-F
What are two components of the subjective assessment? - Answer-HPI/ROS/CC
Which portion of the SOAP note contains the results of orders? - Answer-Objective
The Dr says to the patient, "I'd like you to follow up with your GI doctor in the next two
weeks." In what section of the SOAP note does this belong? - Answer-Plan
Subjective or Objective: Patient says "I have been vomiting on and off for the past 3
days." - Answer-Subjective
Subjective or Objective: Doctor says "There is tenderness in the RUQ" - Answer-
Objective
Subjective or Objective: Doctor says "The blood chemistry shows elevated LFTs" -
Answer-Objective
Subjective or objective: Patient says "My abdominal pain feels dull and cramping" -
Answer-Subjective
Why is it important to include a CC on every chart? - Answer-billing purposes
QUESTIONS WITH CORRECT ANSWERS
Acute vs Chronic - Answer-new onset, to be of concern vs. long standing, not as
concerning
Seen and sent home the same day - Answer-outpatient
Chief complaint is... - Answer-the main reason for the patient's visit
A set of government mandated criteria that must be obtained for every patient - Answer-
meaningful use
Baseline - Answer-An individual's normal state of being
Tasks you CAN complete as a scribe - Answer-- document the history and physical
exam while the physician performs them
- pend orders upon instruction of the provider
- locate previous results to show provider
Scribes cannot... - Answer--touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
You are working at a facility where the nurse completes the ROS for the patient.
However, when you enter the room with the doctor, you notice that one of the patient's
answers contradicts the ROS recorded by the nurse. What should you do? - Answer-
Wait until you exit the patient room and notify the doctor of the discrepancy
A SOAP note for an established patient will be ________ than the note for a new patient
- Answer-shorter
A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - Answer-A Diagnostic visist
Why is documenting a thorough HPI important? - Answer-HPI serves as the basis for
the work up that follows
Elements of the HPI - Answer-Onset, Timing, Location, Quality, Severity, Modifying
Factors, Associated Sx, Context
, 3 primary methods of structuring an outpatient HPI - Answer-Single Complaint Formula
Multiple Complaint Formula
Chronologic (Complex Story)
Which HPI structure is best to use for a complex patient with multiple co-morbidities and
a recent work-up? - Answer-multiple complaint or chronological
What are four important details to include in the HPI of a patient who has been
evaluated by another healthcare provider for similar symptoms? - Answer-- who the
provider was
- what tests were ordered
- test results
- diagnosis
The majority of diabetes patients have... - Answer-T2DM
What are common symptoms of diabetes? - Answer-glucosuria, polyuria, polydipsia
Which DM can be treated with oral medication? - Answer-Type II
T/F: The structure of the SOAP note closely follows the clinic flow - Answer-T
T/F: You will usually document the assessment before documenting the HPI - Answer-F
What are two components of the subjective assessment? - Answer-HPI/ROS/CC
Which portion of the SOAP note contains the results of orders? - Answer-Objective
The Dr says to the patient, "I'd like you to follow up with your GI doctor in the next two
weeks." In what section of the SOAP note does this belong? - Answer-Plan
Subjective or Objective: Patient says "I have been vomiting on and off for the past 3
days." - Answer-Subjective
Subjective or Objective: Doctor says "There is tenderness in the RUQ" - Answer-
Objective
Subjective or Objective: Doctor says "The blood chemistry shows elevated LFTs" -
Answer-Objective
Subjective or objective: Patient says "My abdominal pain feels dull and cramping" -
Answer-Subjective
Why is it important to include a CC on every chart? - Answer-billing purposes
