Scribe Final Exam Questions and
Answers 100% Pass
What medical term describes the surgical removal of the gallbladder? Word -
✔✔Cholecystectomy
What does "PHI" stand for? Expand the abbreviation - ✔✔Protected Health Information
T/F Sharing information about a case with family is allowed, as long as you are scribing
with the physician assigned to the case - ✔✔F
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - ✔✔***NOT Hemorrhagic CVA
Craniotomy for hemorrhagic CVA
OR Craniotomy??
A patient's PCP is on vacation. The patient is scheduled to see the NP who is covering
for the PCP during this time. The patient has never been seen by the NP before. Is this
patient considered a new patient or an established patient? - ✔✔Established
Emily Charlene, All Rights Reserved © 2025 1
,A patient is diagnosed with back strain caused by heavy lifting. As part of the
treatment, the physician discusses 4-5 different back stretching exercises that the patient
can perform every morning and before doing any heavy lifting. The discussion only
takes 10 minutes of a 15 minute Established Patient visit. Would your physician be able
to bill counseling time on this patient? - ✔✔Yes
What medical term would best describe "the likely course or outcome of a disease"? -
✔✔Prognosis
Which section of the chart should you document when you hear the following cue
"what medical problems do you have"? - ✔✔PHx
You are writing an HPI for a patient who presented for hyperlipidemia management. In
the middle of the visit, your patient also reports having recently experienced urinary
symptoms. Which HPI structure would be the best to use in this scenario? - ✔✔Multiple
Complaint structure
Which of the following is NOT a purpose of HITECH? - ✔✔To require government
accountability on health insurance plans available in the market place
To require equal access, opportunity, and affordability for health insurance plans by
screening patient health information
To require patient accountability in paying for their health care visit
Emily Charlene, All Rights Reserved © 2025 2
, What medical term would describe a patient with a history of infection or inflammation
of the liver? - ✔✔Hepatitis
For correct billing and reimbursement to go through, a counseling note requires
documentation of the following: - ✔✔Total time with the patient
Percentage of the time spent counseling
You are writing an HPI for a very complex patient who has had multiple recent hospital
admissions for lung cancer. Which HPI structure would be the best to use in this
scenario? - ✔✔Chronologic Structure
Which of the following would be valid complications for CAD? - ✔✔MI
Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a
NEW patient:
57 year old male patient presented with RLQ abdominal pain, which began 5 days ago.
He states that he was mowing the lawn when the pain began. Patient reports he took
OTC Tylenol yesterday without relief. There has been no nausea, vomiting or diarrhea. -
✔✔Yes, the HPI meets Level 4 billing criteria
What are the possible consequences of a HIPAA violation? - ✔✔Lawsuit against you
and the hospital
Emily Charlene, All Rights Reserved © 2025 3
Answers 100% Pass
What medical term describes the surgical removal of the gallbladder? Word -
✔✔Cholecystectomy
What does "PHI" stand for? Expand the abbreviation - ✔✔Protected Health Information
T/F Sharing information about a case with family is allowed, as long as you are scribing
with the physician assigned to the case - ✔✔F
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - ✔✔***NOT Hemorrhagic CVA
Craniotomy for hemorrhagic CVA
OR Craniotomy??
A patient's PCP is on vacation. The patient is scheduled to see the NP who is covering
for the PCP during this time. The patient has never been seen by the NP before. Is this
patient considered a new patient or an established patient? - ✔✔Established
Emily Charlene, All Rights Reserved © 2025 1
,A patient is diagnosed with back strain caused by heavy lifting. As part of the
treatment, the physician discusses 4-5 different back stretching exercises that the patient
can perform every morning and before doing any heavy lifting. The discussion only
takes 10 minutes of a 15 minute Established Patient visit. Would your physician be able
to bill counseling time on this patient? - ✔✔Yes
What medical term would best describe "the likely course or outcome of a disease"? -
✔✔Prognosis
Which section of the chart should you document when you hear the following cue
"what medical problems do you have"? - ✔✔PHx
You are writing an HPI for a patient who presented for hyperlipidemia management. In
the middle of the visit, your patient also reports having recently experienced urinary
symptoms. Which HPI structure would be the best to use in this scenario? - ✔✔Multiple
Complaint structure
Which of the following is NOT a purpose of HITECH? - ✔✔To require government
accountability on health insurance plans available in the market place
To require equal access, opportunity, and affordability for health insurance plans by
screening patient health information
To require patient accountability in paying for their health care visit
Emily Charlene, All Rights Reserved © 2025 2
, What medical term would describe a patient with a history of infection or inflammation
of the liver? - ✔✔Hepatitis
For correct billing and reimbursement to go through, a counseling note requires
documentation of the following: - ✔✔Total time with the patient
Percentage of the time spent counseling
You are writing an HPI for a very complex patient who has had multiple recent hospital
admissions for lung cancer. Which HPI structure would be the best to use in this
scenario? - ✔✔Chronologic Structure
Which of the following would be valid complications for CAD? - ✔✔MI
Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a
NEW patient:
57 year old male patient presented with RLQ abdominal pain, which began 5 days ago.
He states that he was mowing the lawn when the pain began. Patient reports he took
OTC Tylenol yesterday without relief. There has been no nausea, vomiting or diarrhea. -
✔✔Yes, the HPI meets Level 4 billing criteria
What are the possible consequences of a HIPAA violation? - ✔✔Lawsuit against you
and the hospital
Emily Charlene, All Rights Reserved © 2025 3
