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ScribeAmerica OP Final Exam – Verified Questions & Correct Detailed Answers | 2025/2026 A+ Grade

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The ScribeAmerica Outpatient Final Exam is the comprehensive assessment for scribes completing their training in ambulatory/outpatient care settings. It ensures mastery of the essential skills needed to document accurately and efficiently in clinics and specialty practices. Key areas tested include: Medical Terminology – Prefixes, suffixes, abbreviations, and root words across outpatient specialties. Clinical Documentation – SOAP notes, HPI, ROS, physical exam findings, assessment, and plan. Electronic Health Records (EHR) – Chart navigation, compliance, and outpatient documentation standards. HIPAA & Legal Compliance – Patient privacy, confidentiality, and adherence to documentation rules.

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Uploaded on
December 18, 2025
Number of pages
26
Written in
2025/2026
Type
Exam (elaborations)
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Questions & answers

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ScribeAmerica OP Final Exam questions
and answers 2025\2026 A+ Grade

New Patient
- correct answer No previous records, longer visit, detailed chart



established patient
- correct answer Previous records available from last 3 years, shorter visit, concise chart



Diagnostic visit
- correct answer New problem, chief complaint: new symptom, goal is to determine the cause of the
problem and appropriate treatment



health management
- correct answer check up, CC: routine physical or management of chronic problems, goal is preventative
care and/or assessing progress of ongoing medical problems



Clinic Flow
- correct answer 1. Check-in

2. Physician Evaluation

3. Orders & Results

4. Assessment & Plan

5. Check-out



Quality Measures
- correct answer chief complaint

vital signs

height, weight, BMI

,Smoking Status



What goes in the History and Physical (H&P)
- correct answer HPI, ROS, PE



DDx
- correct answer differential diagnosis



Patient says high blood pressure
- correct answer Hypertension (HTN)



Patient says high cholesterol
- correct answer Hyperlipidemia (HLD)



Patient says thyroid problem
- correct answer Usually Hypothyroidism, sometimes Hyperthyroidism



Patient says diabetes
- correct answer Diabetes Mellitus (DM)



Patient says "I only take pills for my diabetes"
- correct answer Non-Insulin Dependent Diabetes Mellitus (NIDDM)



Patient says "I take shots for my diabetes"
- correct answer Insulin Dependent Diabetes Mellitus (IDDM)



Patient says heart disease
- correct answer Coronary Artery Disease (CAD)



Patient says heart attack
- correct answer Myocardial Infarction (MI) and CAD

, Patient says heart failure
- correct answer Congestive Heart Failure (CHF)



Patient says Irregular heartbeat
- correct answer arrhythmia



Patient says murmur
- correct answer heart murmur



Patient says episodes of abnormally fast/racing heartbeat
- correct answer supraventricular tachycardia (SVT)



Patient says asthma
- correct answer asthma



Patient says Emphysema/Chronic Bronchitis
- correct answer Chronic Obstructive Pulmonary Disease (COPD)



Patient says blood clot in lung
- correct answer Pulmonary Embolism (PE)



Patient says pneumonia
- correct answer Pneumonia (PNA)



Patient says reflux
- correct answer Gastroesophageal Reflux Disease (GERD)



Patient says ulcer
- correct answer Gastric Ulcer or Peptic Ulcer Disease (PUD)



Patient says pancreatitis
- correct answer pancreatitis

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