ScribeAmerica Outpatient (OP) Final
Exam Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2025|2026 Q&A | Instant
Download Pdf
1. What is the most appropriate way to document a patient’s chief
complaint?
A) “Patient seems unwell”
B) “Patient feels sick”
C) “Patient reports 3 days of right lower quadrant abdominal pain”
D) “Patient came to clinic”
Rationale: The chief complaint should be concise, specific, and in the
patient’s own words when possible.
2. Which of the following abbreviations is considered unsafe in
documentation?
,A) BP
B) HR
C) U for unit
D) BMI
Rationale: “U” for unit can be mistaken for “0” or “4,” leading to
medication errors. Use “unit” instead.
3. A patient presents with “dyspnea.” This term refers to:
A) Chest pain
B) Shortness of breath
C) Rapid heartbeat
D) Swelling of the legs
Rationale: Dyspnea is the medical term for difficulty or shortness of breath.
4. Which section of the SOAP note contains the patient’s subjective
complaints?
A) Objective
B) Subjective
C) Assessment
D) Plan
Rationale: The subjective section includes patient-reported symptoms and
history.
5. Which vital sign is most directly indicative of perfusion?
A) Temperature
B) Respiratory rate
,C) Oxygen saturation
D) Blood pressure
Rationale: Blood pressure reflects the force of blood against vessel walls,
indicating perfusion to tissues.
6. A patient presents with polyuria, polydipsia, and polyphagia. Which
condition is most likely?
A) Hypertension
B) Hyperthyroidism
C) Diabetes mellitus
D) Chronic kidney disease
Rationale: Polyuria, polydipsia, and polyphagia are classic signs of
diabetes mellitus.
7. Which abbreviation is acceptable in outpatient documentation?
A) q.d.
B) q.o.d.
C) BID
D) IU
Rationale: “BID” (twice daily) is standard; “q.d.”, “q.o.d.”, and “IU” are
discouraged due to potential misinterpretation.
8. The abbreviation “NKA” in a patient’s chart stands for:
A) No known allergies
B) Not known accurately
C) No known allergies
, D) Normal kidney assessment
Rationale: “NKA” is widely used to indicate that the patient has no known
allergies.
9. Which of the following is an example of a past medical history (PMH)
item?
A) Fever today
B) Right knee pain
C) Family history of diabetes
D) History of appendectomy
Rationale: Past medical history includes illnesses, surgeries, or conditions
the patient has had in the past.
10. A patient presents with sudden onset chest pain radiating to the left
arm. What is the most urgent action for the scribe to document?
A) Schedule follow-up in 2 weeks
B) Notify the physician immediately
C) Document only after the visit
D) Ask the patient to rest and monitor at home
Rationale: Sudden chest pain radiating to the arm is a potential myocardial
infarction; immediate physician notification is critical.
11. Which of the following is the correct anatomical location for
auscultating the mitral valve?
A) Right 2nd intercostal space
B) Left 2nd intercostal space
Exam Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2025|2026 Q&A | Instant
Download Pdf
1. What is the most appropriate way to document a patient’s chief
complaint?
A) “Patient seems unwell”
B) “Patient feels sick”
C) “Patient reports 3 days of right lower quadrant abdominal pain”
D) “Patient came to clinic”
Rationale: The chief complaint should be concise, specific, and in the
patient’s own words when possible.
2. Which of the following abbreviations is considered unsafe in
documentation?
,A) BP
B) HR
C) U for unit
D) BMI
Rationale: “U” for unit can be mistaken for “0” or “4,” leading to
medication errors. Use “unit” instead.
3. A patient presents with “dyspnea.” This term refers to:
A) Chest pain
B) Shortness of breath
C) Rapid heartbeat
D) Swelling of the legs
Rationale: Dyspnea is the medical term for difficulty or shortness of breath.
4. Which section of the SOAP note contains the patient’s subjective
complaints?
A) Objective
B) Subjective
C) Assessment
D) Plan
Rationale: The subjective section includes patient-reported symptoms and
history.
5. Which vital sign is most directly indicative of perfusion?
A) Temperature
B) Respiratory rate
,C) Oxygen saturation
D) Blood pressure
Rationale: Blood pressure reflects the force of blood against vessel walls,
indicating perfusion to tissues.
6. A patient presents with polyuria, polydipsia, and polyphagia. Which
condition is most likely?
A) Hypertension
B) Hyperthyroidism
C) Diabetes mellitus
D) Chronic kidney disease
Rationale: Polyuria, polydipsia, and polyphagia are classic signs of
diabetes mellitus.
7. Which abbreviation is acceptable in outpatient documentation?
A) q.d.
B) q.o.d.
C) BID
D) IU
Rationale: “BID” (twice daily) is standard; “q.d.”, “q.o.d.”, and “IU” are
discouraged due to potential misinterpretation.
8. The abbreviation “NKA” in a patient’s chart stands for:
A) No known allergies
B) Not known accurately
C) No known allergies
, D) Normal kidney assessment
Rationale: “NKA” is widely used to indicate that the patient has no known
allergies.
9. Which of the following is an example of a past medical history (PMH)
item?
A) Fever today
B) Right knee pain
C) Family history of diabetes
D) History of appendectomy
Rationale: Past medical history includes illnesses, surgeries, or conditions
the patient has had in the past.
10. A patient presents with sudden onset chest pain radiating to the left
arm. What is the most urgent action for the scribe to document?
A) Schedule follow-up in 2 weeks
B) Notify the physician immediately
C) Document only after the visit
D) Ask the patient to rest and monitor at home
Rationale: Sudden chest pain radiating to the arm is a potential myocardial
infarction; immediate physician notification is critical.
11. Which of the following is the correct anatomical location for
auscultating the mitral valve?
A) Right 2nd intercostal space
B) Left 2nd intercostal space
