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Final Exam- Scribe | Comprehensive Q&A
For Certification Success
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
What condition correctly describes "A blood clot in the extremities"? - correct-
answer -DVT- deep vein thrombosis
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A patient requires removal of the breast to treat breast cancer. What PSHx would
you record into the chart? - correct-answer -Mastectomy
HCC code - correct-answer -Codes for risk
E&M code - correct-answer -codes for reimbursement
ICD code - correct-answer -codes for diagnosis
Determine which structure best fits the following Assessment.
"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 -Comprehensive summary
What FHx/SHx information is usually asked for pediatric patients? - correct-
answer -Second hand smoke exposure
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Immunization status
What is the medical term for "pass-out"? - correct-answer -Syncope
Which symptom(s) would a patient most likely present with if they had HLD? -
correct-answer -Asymptomatic
T/F. Scribes should complete all charts by entering a scribe attestation before
leaving the shift. - correct-answer -True
A 45 year old male presents to the clinic with a constant, ripping, tearing pain to
his central chest radiating straight to his back with associated nausea that began 1
hour ago. He denies any accompanying dyspnea or diaphoresis. What elements
are missing? - correct-answer -1. Modifying factor
2. Relevant context
3. Severity
A female patient underwent surgery to have her ovary removed. What PSHx
would you record into the chart? - correct-answer -Oophorectomy
Final Exam- Scribe | Comprehensive Q&A
For Certification Success
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
What condition correctly describes "A blood clot in the extremities"? - correct-
answer -DVT- deep vein thrombosis
,2|Page
A patient requires removal of the breast to treat breast cancer. What PSHx would
you record into the chart? - correct-answer -Mastectomy
HCC code - correct-answer -Codes for risk
E&M code - correct-answer -codes for reimbursement
ICD code - correct-answer -codes for diagnosis
Determine which structure best fits the following Assessment.
"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 -Comprehensive summary
What FHx/SHx information is usually asked for pediatric patients? - correct-
answer -Second hand smoke exposure
, 3|Page
Immunization status
What is the medical term for "pass-out"? - correct-answer -Syncope
Which symptom(s) would a patient most likely present with if they had HLD? -
correct-answer -Asymptomatic
T/F. Scribes should complete all charts by entering a scribe attestation before
leaving the shift. - correct-answer -True
A 45 year old male presents to the clinic with a constant, ripping, tearing pain to
his central chest radiating straight to his back with associated nausea that began 1
hour ago. He denies any accompanying dyspnea or diaphoresis. What elements
are missing? - correct-answer -1. Modifying factor
2. Relevant context
3. Severity
A female patient underwent surgery to have her ovary removed. What PSHx
would you record into the chart? - correct-answer -Oophorectomy
