SCRIBEAMERICA OUTPATIENT FINAL
EXAM 2026 PRACTICE SET WITH
ACCURATE QUESTIONS AND SOLUTIONS
⫸ Pain vs. tenderness. Answer: Patient's feeling vs. physician's
assessment
⫸ Benign. Answer: Normal, nothing of concern
⫸ Acute. Answer: New onset, likely concerning
⫸ Chronic. Answer: Long-standing, not of direct concern
⫸ Baseline. Answer: An individual's normal state of being
⫸ Auscultation. Answer: Listening with a stethoscope
⫸ Palpation. Answer: The act of pressing on an area (by the physician)
⫸ Inpatient. Answer: Admitted to the hospital overnight
⫸ Outpatient. Answer: Seen and sent home the same day
,⫸ Chief complaint. Answer: The main reason for the patient's visit
⫸ Mid-Level Provider. Answer: Nurse Practitioner (LNP) or Physician
Assistant (PA) that works under the supervision of a physician to
diagnose and treat patients
⫸ Medical provider. Answer: Mid-level provider that diagnoses and
treats patients
⫸ Nurse or Medical Assistant. Answer: Records medical histories and
symptoms, monitors the patient, completes the meaningful use
requirements, administers medications, assists with procedures
⫸ Clinical provider. Answer: Includes both the mid-level provider and
nurse or medical assistant that are direct patient care
⫸ Scribe. Answer: Documents the patient's visit on behalf of the
physician
⫸ Clerical. Answer: Receptionist and scribe that there is no patient care
and only documentation
⫸ Scribes CAN..... Answer: -Document the history, physical exam,
results, procedures, assessment, and plan
, -Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent
studies
-Record physician interpretations of x-rays and EKGs
⫸ Assessment vs Plan. Answer: Diagnosis vs Treatment
⫸ Scribes CANNOT.... Answer: -Partake in any activity that may affect
patient health or outcome
-Touch patients
-Handle bodily fluids or specimens
-Sign or authenticate any chart or record
-Give verbal orders or submit electronic orders
-NO direct patient care, No patient samples, No using logins other than
your own
⫸ NEW Patient. Answer: No previous records, Longer visit, and
Detailed chart
⫸ ESTABLISHED Patient. Answer: Previous records available, Shorter
visit, and Concise chart
EXAM 2026 PRACTICE SET WITH
ACCURATE QUESTIONS AND SOLUTIONS
⫸ Pain vs. tenderness. Answer: Patient's feeling vs. physician's
assessment
⫸ Benign. Answer: Normal, nothing of concern
⫸ Acute. Answer: New onset, likely concerning
⫸ Chronic. Answer: Long-standing, not of direct concern
⫸ Baseline. Answer: An individual's normal state of being
⫸ Auscultation. Answer: Listening with a stethoscope
⫸ Palpation. Answer: The act of pressing on an area (by the physician)
⫸ Inpatient. Answer: Admitted to the hospital overnight
⫸ Outpatient. Answer: Seen and sent home the same day
,⫸ Chief complaint. Answer: The main reason for the patient's visit
⫸ Mid-Level Provider. Answer: Nurse Practitioner (LNP) or Physician
Assistant (PA) that works under the supervision of a physician to
diagnose and treat patients
⫸ Medical provider. Answer: Mid-level provider that diagnoses and
treats patients
⫸ Nurse or Medical Assistant. Answer: Records medical histories and
symptoms, monitors the patient, completes the meaningful use
requirements, administers medications, assists with procedures
⫸ Clinical provider. Answer: Includes both the mid-level provider and
nurse or medical assistant that are direct patient care
⫸ Scribe. Answer: Documents the patient's visit on behalf of the
physician
⫸ Clerical. Answer: Receptionist and scribe that there is no patient care
and only documentation
⫸ Scribes CAN..... Answer: -Document the history, physical exam,
results, procedures, assessment, and plan
, -Access and document laboratory results and radiology findings
-Locate and obtain PMHx, previous charts, past results, and recent
studies
-Record physician interpretations of x-rays and EKGs
⫸ Assessment vs Plan. Answer: Diagnosis vs Treatment
⫸ Scribes CANNOT.... Answer: -Partake in any activity that may affect
patient health or outcome
-Touch patients
-Handle bodily fluids or specimens
-Sign or authenticate any chart or record
-Give verbal orders or submit electronic orders
-NO direct patient care, No patient samples, No using logins other than
your own
⫸ NEW Patient. Answer: No previous records, Longer visit, and
Detailed chart
⫸ ESTABLISHED Patient. Answer: Previous records available, Shorter
visit, and Concise chart
