SCRIBEAMERICA OP REVISION EXAM TEST 2025
QUESTIONS WITH ANSWERS GUARANTEE A+
✔✔HPI: Chronologic Structure - ✔✔best for pts with multiple comorbidities, pts who
have had a significant workup in the past, or established pts jere for a follow-up of a
chronic illness.
✔✔Chronologic Structure - ✔✔Age and sex
Relevant PMHx
Previous Evaluation
Previous Treatment
Current Complaint(s)
Elements of first complaint
Elements of second complaint
Context
✔✔HPI: Do not use days of the week for onset, instead - ✔✔Count the number of days
since the symptoms started
✔✔HPI: Do not use the word "got," instead - ✔✔use phrasing like "the symptoms
became worse" or "the symptoms worsened"
✔✔HPI: Do not start every sentence the same, instead - ✔✔Vary the beginning of your
sentences and avoid repetition.
✔✔HPI: Do not document self diagnoses in the HPI, instead - ✔✔describe the specific
symptoms affecting the pt
✔✔HPI: Do not include PMHx, PSHx, or SHx that is not relevant to today's visit, instead
- ✔✔document only medical histories, surgeries, or social habits that are relevant to the
current evaluation.
✔✔"I took Tums and it didn't help" - ✔✔The symptoms were unchanged by Tums.
✔✔"I have low back pain, but I always have that." - ✔✔He notes chronic lower back
pain, unchanged from baseline
✔✔"It hurts when I touch it." - ✔✔The symptoms are worsened by palpation of the area.
✔✔"Nothing makes it better or worse." - ✔✔There are no modifying factors.
✔✔"My sister has the same cold." - ✔✔Positive sick content with sister who has similar
symptoms.
, ✔✔"If I try to eat or drink anything, I throw it back up." - ✔✔The vomiting is exacerbated
by PO intake.
✔✔"It feels like a fizzing soda in the middle of my chest." - ✔✔He describes the
symptoms as a "fizzing soda" in his central chest.
✔✔Constitutional - ✔✔Fever, weight loss, sweats
✔✔Eyes - ✔✔Change in vision, eye pain, double vision
✔✔Ear/Nose/Throat - ✔✔Ear ache, nose bleed, congestion, sore throat
✔✔Cardiovascular - ✔✔Chest pain, palpitations, leg swelling
✔✔Respiratory - ✔✔SOB, cough, sputum, wheezing
✔✔Gastrointestinal - ✔✔abdominal pain, N/V/D, black or bloody stools
✔✔Genitourinary - ✔✔Dysuria, Frequency, Urgency, Hematuria
✔✔Musculoskeletal - ✔✔joint pain, muscle pain
✔✔Integumentary/Skin - ✔✔Rash, itching, abrasion, laceration
✔✔Neurological - ✔✔Headache, syncope, seizure, numbness, focal weakness
✔✔Psychiatric - ✔✔Depression, anxiety
✔✔Endocrine - ✔✔Polyuria, polydipsia
✔✔Hematological/Lymph - ✔✔bleeding gums, easy bruising, swollen lymph nodes
✔✔Immunologic - ✔✔HIV/AIDS
✔✔ROS: Physician Led - ✔✔the physician will review all body systems with the pt while
the scribe documents real-time. This occurs immediately after the pt has answered all
questions regarding the CC.
Doctors speak quickly! Only document the symptoms that the doctor asks in order to
avoid committing medical fraud.
✔✔ROS: Nurse Led - ✔✔the nurse will perform a full ROS during his/her initial
assessment, prior to the physician entering the room. The scribe will be able to see the
ROS in the EMR prior to starting documentation
QUESTIONS WITH ANSWERS GUARANTEE A+
✔✔HPI: Chronologic Structure - ✔✔best for pts with multiple comorbidities, pts who
have had a significant workup in the past, or established pts jere for a follow-up of a
chronic illness.
✔✔Chronologic Structure - ✔✔Age and sex
Relevant PMHx
Previous Evaluation
Previous Treatment
Current Complaint(s)
Elements of first complaint
Elements of second complaint
Context
✔✔HPI: Do not use days of the week for onset, instead - ✔✔Count the number of days
since the symptoms started
✔✔HPI: Do not use the word "got," instead - ✔✔use phrasing like "the symptoms
became worse" or "the symptoms worsened"
✔✔HPI: Do not start every sentence the same, instead - ✔✔Vary the beginning of your
sentences and avoid repetition.
✔✔HPI: Do not document self diagnoses in the HPI, instead - ✔✔describe the specific
symptoms affecting the pt
✔✔HPI: Do not include PMHx, PSHx, or SHx that is not relevant to today's visit, instead
- ✔✔document only medical histories, surgeries, or social habits that are relevant to the
current evaluation.
✔✔"I took Tums and it didn't help" - ✔✔The symptoms were unchanged by Tums.
✔✔"I have low back pain, but I always have that." - ✔✔He notes chronic lower back
pain, unchanged from baseline
✔✔"It hurts when I touch it." - ✔✔The symptoms are worsened by palpation of the area.
✔✔"Nothing makes it better or worse." - ✔✔There are no modifying factors.
✔✔"My sister has the same cold." - ✔✔Positive sick content with sister who has similar
symptoms.
, ✔✔"If I try to eat or drink anything, I throw it back up." - ✔✔The vomiting is exacerbated
by PO intake.
✔✔"It feels like a fizzing soda in the middle of my chest." - ✔✔He describes the
symptoms as a "fizzing soda" in his central chest.
✔✔Constitutional - ✔✔Fever, weight loss, sweats
✔✔Eyes - ✔✔Change in vision, eye pain, double vision
✔✔Ear/Nose/Throat - ✔✔Ear ache, nose bleed, congestion, sore throat
✔✔Cardiovascular - ✔✔Chest pain, palpitations, leg swelling
✔✔Respiratory - ✔✔SOB, cough, sputum, wheezing
✔✔Gastrointestinal - ✔✔abdominal pain, N/V/D, black or bloody stools
✔✔Genitourinary - ✔✔Dysuria, Frequency, Urgency, Hematuria
✔✔Musculoskeletal - ✔✔joint pain, muscle pain
✔✔Integumentary/Skin - ✔✔Rash, itching, abrasion, laceration
✔✔Neurological - ✔✔Headache, syncope, seizure, numbness, focal weakness
✔✔Psychiatric - ✔✔Depression, anxiety
✔✔Endocrine - ✔✔Polyuria, polydipsia
✔✔Hematological/Lymph - ✔✔bleeding gums, easy bruising, swollen lymph nodes
✔✔Immunologic - ✔✔HIV/AIDS
✔✔ROS: Physician Led - ✔✔the physician will review all body systems with the pt while
the scribe documents real-time. This occurs immediately after the pt has answered all
questions regarding the CC.
Doctors speak quickly! Only document the symptoms that the doctor asks in order to
avoid committing medical fraud.
✔✔ROS: Nurse Led - ✔✔the nurse will perform a full ROS during his/her initial
assessment, prior to the physician entering the room. The scribe will be able to see the
ROS in the EMR prior to starting documentation
