©THESTAR 2024/2025 ALL RIGHTS RESERVED.
Scribe Final Exam Questions And Correct
Answers 100% Verified.
What medical term describes the surgical removal of the gallbladder? Word -
Answer✔Cholecystectomy
What does "PHI" stand for? Expand the abbreviation - Answer✔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 - Answer✔F
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would
you record into the chart? - Answer✔***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? - Answer✔Established
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? -
Answer✔Yes
What medical term would best describe "the likely course or outcome of a disease"? -
Answer✔Prognosis
Which section of the chart should you document when you hear the following cue "what medical
problems do you have"? - Answer✔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? - Answer✔Multiple Complaint
structure
1|Page
, ©THESTAR 2024/2025 ALL RIGHTS RESERVED.
Which of the following is NOT a purpose of HITECH? - Answer✔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
What medical term would describe a patient with a history of infection or inflammation of the
liver? - Answer✔Hepatitis
For correct billing and reimbursement to go through, a counseling note requires documentation
of the following: - Answer✔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? -
Answer✔Chronologic Structure
Which of the following would be valid complications for CAD? - Answer✔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. - Answer✔Yes, the
HPI meets Level 4 billing criteria
What are the possible consequences of a HIPAA violation? - Answer✔Lawsuit against you and
the hospital
Monetary fines to you and the hospital
Scribe program cancellation
Termination
Prison time
Violator is blacklisted from medical programs like Medical, PA, or NP school
What does HIPAA stand for? Expand the abbreviation. - Answer✔Health Insurance Portability
& Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? -
Answer✔Diabetes Mellitus
2|Page
Scribe Final Exam Questions And Correct
Answers 100% Verified.
What medical term describes the surgical removal of the gallbladder? Word -
Answer✔Cholecystectomy
What does "PHI" stand for? Expand the abbreviation - Answer✔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 - Answer✔F
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would
you record into the chart? - Answer✔***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? - Answer✔Established
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? -
Answer✔Yes
What medical term would best describe "the likely course or outcome of a disease"? -
Answer✔Prognosis
Which section of the chart should you document when you hear the following cue "what medical
problems do you have"? - Answer✔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? - Answer✔Multiple Complaint
structure
1|Page
, ©THESTAR 2024/2025 ALL RIGHTS RESERVED.
Which of the following is NOT a purpose of HITECH? - Answer✔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
What medical term would describe a patient with a history of infection or inflammation of the
liver? - Answer✔Hepatitis
For correct billing and reimbursement to go through, a counseling note requires documentation
of the following: - Answer✔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? -
Answer✔Chronologic Structure
Which of the following would be valid complications for CAD? - Answer✔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. - Answer✔Yes, the
HPI meets Level 4 billing criteria
What are the possible consequences of a HIPAA violation? - Answer✔Lawsuit against you and
the hospital
Monetary fines to you and the hospital
Scribe program cancellation
Termination
Prison time
Violator is blacklisted from medical programs like Medical, PA, or NP school
What does HIPAA stand for? Expand the abbreviation. - Answer✔Health Insurance Portability
& Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or HbA1c? -
Answer✔Diabetes Mellitus
2|Page
