Scribe America REAL EXAM REVIEW 150 QUESTIONS AND CORRECT
ANSWERS WITH DETAILED ANSWERS COVERING THE MOST TESTED
QUESTIONS PERFECT FOR A+ GRADE
1. What is the main responsibility of a medical scribe?
A) Diagnose and treat patients
B) Order laboratory tests
C) Document the provider’s encounters accurately
D) Explain results to the patient
Rationale: Scribes document medical encounters in real-time but do not provide patient care or make
medical decisions.
2. The abbreviation “SOB” stands for:
A) Swelling of bones
B) Shortness of breath
C) Severe onset bronchitis
D) Sudden obstruction
Rationale: SOB is a standard abbreviation for “shortness of breath” used in clinical documentation.
3. Which of the following is protected under HIPAA?
A) General health statistics
B) Medical textbook examples
C) Patient’s date of birth and diagnosis
D) Hospital cafeteria menu
Rationale: HIPAA protects all personally identifiable patient health information.
4. In a patient note, “CC” stands for:
A) Chronic complaint
B) Chief complaint
C) Clinical confirmation
D) Cardiac condition
Rationale: The Chief Complaint (CC) is the main reason the patient is seeking care.
5. Which section of the chart details the provider’s assessment and next steps?
A) HPI
B) ROS
C) Plan
,D) PE
Rationale: The “Plan” section contains treatment plans, medications, and follow-up instructions.
6. A 45-year-old male presents with chest pain radiating to his left arm. This information belongs in
which section?
A) ROS
B) PMH
C) HPI
D) PE
Rationale: The History of Present Illness (HPI) details the current complaint, including onset, timing, and
quality.
7. What does the abbreviation “NKDA” mean?
A) No kidney disease available
B) No known drug allergies
C) Not keeping daily appointments
D) Normal knee drop angle
Rationale: NKDA means the patient reports no known drug allergies.
8. When should a scribe log out of an EHR workstation?
A) After shift ends
B) Whenever leaving the computer unattended
C) Only at the end of the patient encounter
D) When the provider requests
Rationale: HIPAA requires you to log out when leaving any workstation to prevent unauthorized access.
9. What is the correct order of documentation in a patient encounter?
A) PE → Plan → HPI
B) ROS → HPI → PE
C) HPI → ROS → PE → Assessment/Plan
D) Chief Complaint → Plan → Assessment
Rationale: Standard documentation order follows the SOAP or similar structure for clarity and accuracy.
10. The term “tachycardia” means:
A) Slow heart rate
B) Fast heart rate
C) Irregular breathing
, D) Low blood pressure
Rationale: “Tachy-” means rapid, and “-cardia” refers to the heart.
11. The ROS section includes:
A) Physical exam findings
B) Patient-reported symptoms in all body systems
C) Only abnormal lab results
D) Provider diagnosis
Rationale: The Review of Systems lists patient symptoms organized by body system.
12. If a provider says “The patient is afebrile,” what does that mean?
A) Feverish
B) No fever
C) Sweating heavily
D) Low body temperature
Rationale: “Afebrile” means without fever.
13. What is considered a legal document in a medical setting?
A) Doctor’s verbal note
B) The patient’s chart/EHR
C) Physician’s memory
D) Daily census log
Rationale: The patient’s chart is a legal document that can be used in audits or court proceedings.
14. Which of the following abbreviations means “as needed”?
A) BID
B) TID
C) PRN
D) QHS
Rationale: PRN = “pro re nata” = “as needed.”
15. Which action should a scribe take if the provider dictates something that seems incorrect?
A) Correct it independently
B) Skip it
C) Clarify with the provider
D) Report to administration
Rationale: Always confirm directly with the provider for accuracy.
ANSWERS WITH DETAILED ANSWERS COVERING THE MOST TESTED
QUESTIONS PERFECT FOR A+ GRADE
1. What is the main responsibility of a medical scribe?
A) Diagnose and treat patients
B) Order laboratory tests
C) Document the provider’s encounters accurately
D) Explain results to the patient
Rationale: Scribes document medical encounters in real-time but do not provide patient care or make
medical decisions.
2. The abbreviation “SOB” stands for:
A) Swelling of bones
B) Shortness of breath
C) Severe onset bronchitis
D) Sudden obstruction
Rationale: SOB is a standard abbreviation for “shortness of breath” used in clinical documentation.
3. Which of the following is protected under HIPAA?
A) General health statistics
B) Medical textbook examples
C) Patient’s date of birth and diagnosis
D) Hospital cafeteria menu
Rationale: HIPAA protects all personally identifiable patient health information.
4. In a patient note, “CC” stands for:
A) Chronic complaint
B) Chief complaint
C) Clinical confirmation
D) Cardiac condition
Rationale: The Chief Complaint (CC) is the main reason the patient is seeking care.
5. Which section of the chart details the provider’s assessment and next steps?
A) HPI
B) ROS
C) Plan
,D) PE
Rationale: The “Plan” section contains treatment plans, medications, and follow-up instructions.
6. A 45-year-old male presents with chest pain radiating to his left arm. This information belongs in
which section?
A) ROS
B) PMH
C) HPI
D) PE
Rationale: The History of Present Illness (HPI) details the current complaint, including onset, timing, and
quality.
7. What does the abbreviation “NKDA” mean?
A) No kidney disease available
B) No known drug allergies
C) Not keeping daily appointments
D) Normal knee drop angle
Rationale: NKDA means the patient reports no known drug allergies.
8. When should a scribe log out of an EHR workstation?
A) After shift ends
B) Whenever leaving the computer unattended
C) Only at the end of the patient encounter
D) When the provider requests
Rationale: HIPAA requires you to log out when leaving any workstation to prevent unauthorized access.
9. What is the correct order of documentation in a patient encounter?
A) PE → Plan → HPI
B) ROS → HPI → PE
C) HPI → ROS → PE → Assessment/Plan
D) Chief Complaint → Plan → Assessment
Rationale: Standard documentation order follows the SOAP or similar structure for clarity and accuracy.
10. The term “tachycardia” means:
A) Slow heart rate
B) Fast heart rate
C) Irregular breathing
, D) Low blood pressure
Rationale: “Tachy-” means rapid, and “-cardia” refers to the heart.
11. The ROS section includes:
A) Physical exam findings
B) Patient-reported symptoms in all body systems
C) Only abnormal lab results
D) Provider diagnosis
Rationale: The Review of Systems lists patient symptoms organized by body system.
12. If a provider says “The patient is afebrile,” what does that mean?
A) Feverish
B) No fever
C) Sweating heavily
D) Low body temperature
Rationale: “Afebrile” means without fever.
13. What is considered a legal document in a medical setting?
A) Doctor’s verbal note
B) The patient’s chart/EHR
C) Physician’s memory
D) Daily census log
Rationale: The patient’s chart is a legal document that can be used in audits or court proceedings.
14. Which of the following abbreviations means “as needed”?
A) BID
B) TID
C) PRN
D) QHS
Rationale: PRN = “pro re nata” = “as needed.”
15. Which action should a scribe take if the provider dictates something that seems incorrect?
A) Correct it independently
B) Skip it
C) Clarify with the provider
D) Report to administration
Rationale: Always confirm directly with the provider for accuracy.
