SCRIBE FINAL EXAM QUESTIONS AND
CORRECT ANSWERS. VERIFIED
2025/2026.
What medical term describes the surgical removal of the gallbladder? - ANS Cholecystectomy
What does "PHI" stand for? - ANS 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. - ANS False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record into the chart? - ANS 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? - ANS Established
A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the
physician discusses 4-5 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. Would your physician be able to bill counseling time on this patient? -
ANS Yes
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, What medical term would best describe "the likely course or outcome of a disease"? -
ANS Prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have"? - ANS PHx
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? - ANS Multiple complaints
structure
Which of the following is NOT a purpose of HITECH? - ANS 1. To require equal access,
opportunity, and affordability for health insurance plans by screening patient health information
2. To require government accountability on health insurance plans available in the market place
3. To require encryption when using technology to transmit patient related information
4. To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or inflammation of the
liver? - ANS Hepatitis
For correct billing and reimbursement to go through, a counseling note requires
docuementation of the following: - ANS 1. Total time with the patient
2. 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 the best to use in this scenario? -
ANS Chronologic Structure and Multiple complaints structure
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
CORRECT ANSWERS. VERIFIED
2025/2026.
What medical term describes the surgical removal of the gallbladder? - ANS Cholecystectomy
What does "PHI" stand for? - ANS 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. - ANS False
A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx
would you record into the chart? - ANS 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? - ANS Established
A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the
physician discusses 4-5 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. Would your physician be able to bill counseling time on this patient? -
ANS Yes
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, What medical term would best describe "the likely course or outcome of a disease"? -
ANS Prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have"? - ANS PHx
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? - ANS Multiple complaints
structure
Which of the following is NOT a purpose of HITECH? - ANS 1. To require equal access,
opportunity, and affordability for health insurance plans by screening patient health information
2. To require government accountability on health insurance plans available in the market place
3. To require encryption when using technology to transmit patient related information
4. To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or inflammation of the
liver? - ANS Hepatitis
For correct billing and reimbursement to go through, a counseling note requires
docuementation of the following: - ANS 1. Total time with the patient
2. 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 the best to use in this scenario? -
ANS Chronologic Structure and Multiple complaints structure
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
