Scribeamerica Final Exam LATEST VERSION 260 QUESTIONS AND
ANSWERS WITH PRACTICE EXAMS VERIFIED FOR GUARANTEED
PASS, LATEST UPDATE 2025
What does IDDM stand for? - CORRECT ANSWER insulin dependent diabetes
mellitus
What does AMS stand for? - CORRECT ANSWER altered mental status
A patient states she has had a productive cough for four days, and yesterday she
developed a fever. Would her fever be considered an associated symptoms for her
productive cough? Why or why not? - CORRECT ANSWER Yes. The fever started
soon after her cough.
Match each critical care, diagnosis with its associated procedure. - CORRECT
ANSWER Respiratory failure=intubation
acute exacerbation=CPAP, BiPAP
cardiac arrest=CPR
PTX(Pneumothorax)=chest tube
sepsis=central line placement
abnormal heart rhythm=cardioversion
What does GCS stand for? - CORRECT ANSWER Glasgow Coma Scale
What does DVT stand for? - CORRECT ANSWER deep vein thrombosis
What does PE stand for? - CORRECT ANSWER pulmonary embolism
Among the following diseases listed, select the ones that qualify for CCT. - CORRECT
ANSWER ACS, CVA, Afib, acute MI, DKA, PTX, PE, sepsis NOT pleuritis, stable
angina, or costochondritis
What is the medical term for coughing up blood? - CORRECT ANSWER
hemoptysis
,Which of these procedures qualify as critical care procedures, and would indicate that
critical care time must be documented on a patient? - CORRECT ANSWER
Conscious Sedation
Central line placement
LP
If a patient signs a waiver, giving you permission to capture a photo of their unique rash,
would you be committing a HIPAA violation by using your cell phone to capture the
photo? - CORRECT ANSWER Yes, because the phone is not an approved hospital
device and it is not encrypted.
What procedure would be used to diagnose meningitis? - CORRECT ANSWER
Lumbar puncture
A female patient has been pregnant four times in the past, is currently pregnant, and
has two children at home. Calculate the GPA and a respectively. - CORRECT
ANSWER 5,2,2
What does AAA stand for? - CORRECT ANSWER abdominal aortic aneurysm
George is employed with scribe America as a scribe. He was off today and accidentally
cut his check while practicing his sword swallowing skills. He goes to the emergency
department and is seen by a doctor and another scribe. The emergency department is
extremely busy and so George decides to help out the doctor by describing his own
note using the computer in the room. Has George taken the appropriate steps in the
situation? - CORRECT ANSWER No, because George access his own medical
records using his EMR login.
What FHx/SHx information is usually asked for pediatric patients? (Select all that apply.)
- CORRECT ANSWER Second hand smoke exposure, immunization records
What medical term describes the surgical removal of the gallbladder? - CORRECT
ANSWER cholecystectomy
what does PHI stand for? - CORRECT 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. - CORRECT ANSWER False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - CORRECT ANSWER 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? - CORRECT ANSWER
Established
A patient is diagnosed with back strain caused by heavy, lifting. As part of the treatment,
the physician discusses 4 to 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. What is your position be able to bill
counseling time on this patient? - CORRECT ANSWER Yes
What medical term would best describe the likely course or outcome of a disease? -
CORRECT ANSWER prognosis
Which section of the chart should you document? When you hear of the following Q?
What medical problems do you have? - CORRECT ANSWER Hx
You are writing an HPI for a patient who presented for hyper lipidemia 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? - CORRECT
ANSWER Multiple complaints structure
Which of the following is not a purpose of HITECH? - CORRECT ANSWER To
require patient accountability and paying for their healthcare visit, to require a
government accountability on health insurance plans available in the market Place, to
require equal access, opportunity, and affordability for healthcare insurance plans by
screening patient health information
What medical term would describe a patient with a history of infection or inflammation of
the liver - CORRECT ANSWER hepatitis
Four correct billing and reimbursement to go through a counseling note requires
documentation of the following - CORRECT ANSWER Percentage of 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 best to use in this scenario. -
CORRECT ANSWER Chronologic Structure
Which of the following would be valid complications for CAD - CORRECT ANSWER
mi
57-year-old male patient presented with RLQ abdominal pain, which began five days
ago. He states that he was mowing the lawn when the pain began. Patient reports he
ANSWERS WITH PRACTICE EXAMS VERIFIED FOR GUARANTEED
PASS, LATEST UPDATE 2025
What does IDDM stand for? - CORRECT ANSWER insulin dependent diabetes
mellitus
What does AMS stand for? - CORRECT ANSWER altered mental status
A patient states she has had a productive cough for four days, and yesterday she
developed a fever. Would her fever be considered an associated symptoms for her
productive cough? Why or why not? - CORRECT ANSWER Yes. The fever started
soon after her cough.
Match each critical care, diagnosis with its associated procedure. - CORRECT
ANSWER Respiratory failure=intubation
acute exacerbation=CPAP, BiPAP
cardiac arrest=CPR
PTX(Pneumothorax)=chest tube
sepsis=central line placement
abnormal heart rhythm=cardioversion
What does GCS stand for? - CORRECT ANSWER Glasgow Coma Scale
What does DVT stand for? - CORRECT ANSWER deep vein thrombosis
What does PE stand for? - CORRECT ANSWER pulmonary embolism
Among the following diseases listed, select the ones that qualify for CCT. - CORRECT
ANSWER ACS, CVA, Afib, acute MI, DKA, PTX, PE, sepsis NOT pleuritis, stable
angina, or costochondritis
What is the medical term for coughing up blood? - CORRECT ANSWER
hemoptysis
,Which of these procedures qualify as critical care procedures, and would indicate that
critical care time must be documented on a patient? - CORRECT ANSWER
Conscious Sedation
Central line placement
LP
If a patient signs a waiver, giving you permission to capture a photo of their unique rash,
would you be committing a HIPAA violation by using your cell phone to capture the
photo? - CORRECT ANSWER Yes, because the phone is not an approved hospital
device and it is not encrypted.
What procedure would be used to diagnose meningitis? - CORRECT ANSWER
Lumbar puncture
A female patient has been pregnant four times in the past, is currently pregnant, and
has two children at home. Calculate the GPA and a respectively. - CORRECT
ANSWER 5,2,2
What does AAA stand for? - CORRECT ANSWER abdominal aortic aneurysm
George is employed with scribe America as a scribe. He was off today and accidentally
cut his check while practicing his sword swallowing skills. He goes to the emergency
department and is seen by a doctor and another scribe. The emergency department is
extremely busy and so George decides to help out the doctor by describing his own
note using the computer in the room. Has George taken the appropriate steps in the
situation? - CORRECT ANSWER No, because George access his own medical
records using his EMR login.
What FHx/SHx information is usually asked for pediatric patients? (Select all that apply.)
- CORRECT ANSWER Second hand smoke exposure, immunization records
What medical term describes the surgical removal of the gallbladder? - CORRECT
ANSWER cholecystectomy
what does PHI stand for? - CORRECT 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. - CORRECT ANSWER False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What
PSHx would you record into the chart? - CORRECT ANSWER 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? - CORRECT ANSWER
Established
A patient is diagnosed with back strain caused by heavy, lifting. As part of the treatment,
the physician discusses 4 to 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. What is your position be able to bill
counseling time on this patient? - CORRECT ANSWER Yes
What medical term would best describe the likely course or outcome of a disease? -
CORRECT ANSWER prognosis
Which section of the chart should you document? When you hear of the following Q?
What medical problems do you have? - CORRECT ANSWER Hx
You are writing an HPI for a patient who presented for hyper lipidemia 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? - CORRECT
ANSWER Multiple complaints structure
Which of the following is not a purpose of HITECH? - CORRECT ANSWER To
require patient accountability and paying for their healthcare visit, to require a
government accountability on health insurance plans available in the market Place, to
require equal access, opportunity, and affordability for healthcare insurance plans by
screening patient health information
What medical term would describe a patient with a history of infection or inflammation of
the liver - CORRECT ANSWER hepatitis
Four correct billing and reimbursement to go through a counseling note requires
documentation of the following - CORRECT ANSWER Percentage of 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 best to use in this scenario. -
CORRECT ANSWER Chronologic Structure
Which of the following would be valid complications for CAD - CORRECT ANSWER
mi
57-year-old male patient presented with RLQ abdominal pain, which began five days
ago. He states that he was mowing the lawn when the pain began. Patient reports he
