SCRIBE AMERICA OUTPATIENT NEWEST
2025-2026 ACTUAL EXAM WITH COMPLETE
QUESTIONS AND CORRECT ANSWERS
RATED A+
Scribe Role Correct Answer Share clinicians burden of data
gathering and chart documentation
Present during all data gathering including patient conversation,
physical exam, labs and imaging, and re-evaluations
Updates Electronic Health Record (EHR) for the provider so they
can focus on patient
Scope of a Scribe Correct Answer CAN:
- Document history, physical exam, results, procedures, and
consults
- Access and document laboratory results and radiology findings
- Access and display X-rays for the physician to review
- Locate and obtain medical history, previous charts and past
results
- Record physician interpretations of X-rays and ECGs
,CANNOT:
- Touch patients
- Write orders or prescriptions
- Give verbal orders
- Sign or authenticate any chart or record (on behalf of provider)
- Handle bodily fluids or specimens
EMR/ EHR Correct Answer Electronic Medical Record/Electronic
Health Record
Subjective vs objective Correct Answer Sub: feeling, obtained by
patient
- ex: nausea
Ob: factual finding from the provider
pain vs tenderness Correct Answer Pain is a subjective term
(patients feeling of discomfort)
Tenderness is an objective term (reproducible pain found by
provider)
,acute vs chronic Correct Answer new onset (likely concerning) vs.
long standing (not of direct concern)
New patients Correct Answer pt who has never been seen at the
clinic, OR was seen over 3 years ago
No previous records, longer visit, detailed chart
Diagnostic visit Correct Answer New problem; chief complaint is a
new symptom
Goal is to determine the cause of the problem and appropriate
treatment
Trick ex: established patient w/ new hand rash that needs to be
diagnosed
Established patients Correct Answer Pt seen at the clinic (by an
provider) within the last 3 years
Previous records available, shorter visit, concise chart
Clinic flow Correct Answer 1. Check-in & chief complaint
2. History & physical
, 3. Orders & Results
4. Assessment & Plan
5. Check-out
Health management visit Correct Answer Check-up; Chief
Complaint: Routine physical or management of chronic
problem(s)
Goal is preventative care and/or assessing progress of ongoing
medical problems
Trick ex: new patient seeking care from new provider for chronic
issue
Check in & chief complaint Correct Answer Patient arrives (walk-
in or EMS) & assigned a room
Nurse or MA assessment
- diagnostic or health management
- vital signs (HR, BP, RR, temp, SaO2)
- height, weight, smoking status, allergies, medications
history and physical Correct Answer Before entering room:
2025-2026 ACTUAL EXAM WITH COMPLETE
QUESTIONS AND CORRECT ANSWERS
RATED A+
Scribe Role Correct Answer Share clinicians burden of data
gathering and chart documentation
Present during all data gathering including patient conversation,
physical exam, labs and imaging, and re-evaluations
Updates Electronic Health Record (EHR) for the provider so they
can focus on patient
Scope of a Scribe Correct Answer CAN:
- Document history, physical exam, results, procedures, and
consults
- Access and document laboratory results and radiology findings
- Access and display X-rays for the physician to review
- Locate and obtain medical history, previous charts and past
results
- Record physician interpretations of X-rays and ECGs
,CANNOT:
- Touch patients
- Write orders or prescriptions
- Give verbal orders
- Sign or authenticate any chart or record (on behalf of provider)
- Handle bodily fluids or specimens
EMR/ EHR Correct Answer Electronic Medical Record/Electronic
Health Record
Subjective vs objective Correct Answer Sub: feeling, obtained by
patient
- ex: nausea
Ob: factual finding from the provider
pain vs tenderness Correct Answer Pain is a subjective term
(patients feeling of discomfort)
Tenderness is an objective term (reproducible pain found by
provider)
,acute vs chronic Correct Answer new onset (likely concerning) vs.
long standing (not of direct concern)
New patients Correct Answer pt who has never been seen at the
clinic, OR was seen over 3 years ago
No previous records, longer visit, detailed chart
Diagnostic visit Correct Answer New problem; chief complaint is a
new symptom
Goal is to determine the cause of the problem and appropriate
treatment
Trick ex: established patient w/ new hand rash that needs to be
diagnosed
Established patients Correct Answer Pt seen at the clinic (by an
provider) within the last 3 years
Previous records available, shorter visit, concise chart
Clinic flow Correct Answer 1. Check-in & chief complaint
2. History & physical
, 3. Orders & Results
4. Assessment & Plan
5. Check-out
Health management visit Correct Answer Check-up; Chief
Complaint: Routine physical or management of chronic
problem(s)
Goal is preventative care and/or assessing progress of ongoing
medical problems
Trick ex: new patient seeking care from new provider for chronic
issue
Check in & chief complaint Correct Answer Patient arrives (walk-
in or EMS) & assigned a room
Nurse or MA assessment
- diagnostic or health management
- vital signs (HR, BP, RR, temp, SaO2)
- height, weight, smoking status, allergies, medications
history and physical Correct Answer Before entering room:
