ScribeAmerica Outpatient Final – Complete Course Review &
Exam Prep (Updated 2025/2026)
What does "PHI" stand for? Expand the abbreviation - correct answerprotected health
information
What medical term describes the surgical removal of the gallbladder? - correct
answercholecystectomy
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 answerFalse
A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering
for the PCP during this time. The patient has never been seen by the NP before. Is the
patient considered a new patient or an established patient? - correct answerEstablished
What is the medical abbreviation for the condition commonly described as "reflux" -
correct answerGERD
What medical term would best describe "the likely course or outcome of a disease?" -
correct answerprognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have?" - correct answerPHx
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? - correct
answermultiple complaints structure
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? - correct answerchronological structure
Which of the following would be valid complications for CAD? (Select all that apply) -
correct answerMI
11. What are the possible consequences of a HIPAA violation? (Select all that apply) -
correct answer*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
,*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. - correct answerHealth
Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? Two words, expand the abbreviation. - correct answerdiabetes mellitus
A patient states she has had a productive cough for 4 days, and yesterday she
developed a fever. Would her fever be considered an associated symptom for her
productive cough? Why or why not? - correct answerYes, because the fever started
soon after the cough
15. Which of the following would be documented in the Objective section of the SOAP
note? (select all that apply) - correct answer*Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to__________. (select the best option) - correct
answermaintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood clot in the
lungs"? (Use the abbreviation form of the condition) - correct answerPE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. - correct answerHLD
Which of the following are considered non-reimbursable chief complaints? (Select all
that apply) - correct answer*follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork and does
not know what medications he should be taking at home. He asks you to look up his
medical record when you go to your shift today, giving you verbal permission to access
his information. In this scenario, it is justifiable for you to use your EMR login to look up
the important patient information. - correct answerFalse
A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic
condition should be included in their diagnosis today? Expand the abbreviation? -
correct answercoronary artery disease
, A patient states that he has been having abdominal pain for the last three days, and it
varies between mild and severe. Which of the following would best describe the Timing?
- correct answerWaxing and waning
The patient reports a tenderness in their right upper abdomen that began 2 weeks ago.
Based on that information, do you document RUQ tenderness under the physical
exam? - correct answerNo
What condition correctly describes "heart attack"? Use the abbreviated form of the
condition. - correct answerMI
A patient reportedly had their tonsils removed as a child. What PSHx would you record
into the chart? - correct answertonsillectomy
What is the medical term for an elevated heart rate (over 100 beats per minute)? -
correct answertachycardia
27. Identify what details are included in the following Assessment. (Select all that apply.)
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation
today. He reports decreased urinary output that has progressively worsened since onset
5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks
ago. Patient recommended emergency dialysis today and warned that he may be at risk
for death and other complications if he does not seek further urgent medical attention.
Patient understands and agrees to be transferred to the ED." - correct answer*Age and
sex
*PHx, if relevant
*Diagnosis
*Results
*HPI
*Prognosis/Plan
T/F. All symptoms documented in the ROS are also documented in the HPI. - correct
answerFalse
What is the medical term for "open heart surgery"? Expand the abbreviation - correct
answercoronary artery bypass graft
30. Identify which of these PE systems contains contradictory findings: - correct
answerRespiratory: No respiratory distress, tachypnea, lungs clear to auscultation
bilaterally
If a patient signs a waiver giving you permission to capture photo of their unique rash,
would you be committing a HIPAA violation by using your cellphone to capture the
photo? Select best - correct answerYes because the phone is not an approved hospital
device and it is not encrypted
Exam Prep (Updated 2025/2026)
What does "PHI" stand for? Expand the abbreviation - correct answerprotected health
information
What medical term describes the surgical removal of the gallbladder? - correct
answercholecystectomy
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 answerFalse
A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering
for the PCP during this time. The patient has never been seen by the NP before. Is the
patient considered a new patient or an established patient? - correct answerEstablished
What is the medical abbreviation for the condition commonly described as "reflux" -
correct answerGERD
What medical term would best describe "the likely course or outcome of a disease?" -
correct answerprognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have?" - correct answerPHx
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? - correct
answermultiple complaints structure
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? - correct answerchronological structure
Which of the following would be valid complications for CAD? (Select all that apply) -
correct answerMI
11. What are the possible consequences of a HIPAA violation? (Select all that apply) -
correct answer*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
,*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. - correct answerHealth
Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? Two words, expand the abbreviation. - correct answerdiabetes mellitus
A patient states she has had a productive cough for 4 days, and yesterday she
developed a fever. Would her fever be considered an associated symptom for her
productive cough? Why or why not? - correct answerYes, because the fever started
soon after the cough
15. Which of the following would be documented in the Objective section of the SOAP
note? (select all that apply) - correct answer*Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to__________. (select the best option) - correct
answermaintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood clot in the
lungs"? (Use the abbreviation form of the condition) - correct answerPE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. - correct answerHLD
Which of the following are considered non-reimbursable chief complaints? (Select all
that apply) - correct answer*follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork and does
not know what medications he should be taking at home. He asks you to look up his
medical record when you go to your shift today, giving you verbal permission to access
his information. In this scenario, it is justifiable for you to use your EMR login to look up
the important patient information. - correct answerFalse
A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic
condition should be included in their diagnosis today? Expand the abbreviation? -
correct answercoronary artery disease
, A patient states that he has been having abdominal pain for the last three days, and it
varies between mild and severe. Which of the following would best describe the Timing?
- correct answerWaxing and waning
The patient reports a tenderness in their right upper abdomen that began 2 weeks ago.
Based on that information, do you document RUQ tenderness under the physical
exam? - correct answerNo
What condition correctly describes "heart attack"? Use the abbreviated form of the
condition. - correct answerMI
A patient reportedly had their tonsils removed as a child. What PSHx would you record
into the chart? - correct answertonsillectomy
What is the medical term for an elevated heart rate (over 100 beats per minute)? -
correct answertachycardia
27. Identify what details are included in the following Assessment. (Select all that apply.)
"Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation
today. He reports decreased urinary output that has progressively worsened since onset
5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks
ago. Patient recommended emergency dialysis today and warned that he may be at risk
for death and other complications if he does not seek further urgent medical attention.
Patient understands and agrees to be transferred to the ED." - correct answer*Age and
sex
*PHx, if relevant
*Diagnosis
*Results
*HPI
*Prognosis/Plan
T/F. All symptoms documented in the ROS are also documented in the HPI. - correct
answerFalse
What is the medical term for "open heart surgery"? Expand the abbreviation - correct
answercoronary artery bypass graft
30. Identify which of these PE systems contains contradictory findings: - correct
answerRespiratory: No respiratory distress, tachypnea, lungs clear to auscultation
bilaterally
If a patient signs a waiver giving you permission to capture photo of their unique rash,
would you be committing a HIPAA violation by using your cellphone to capture the
photo? Select best - correct answerYes because the phone is not an approved hospital
device and it is not encrypted
