SCRIBEAMERICA OUTPATIENT FINAL 203 2026
MEDICAL SCRIBING CERTIFICATION TEST
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ pain vs tenderness. Answer: patients feeling vs physicians
assessment
◉ benign. Answer: normal, nothing of concern
◉ acute vs chronic. Answer: new onset vs long standing
◉ baseline. Answer: an individuals normal state of being
◉ ausculation. Answer: listening to sound with a stethoscope
◉ palpation. Answer: 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: main reason for the patients visit
◉ meaningful use. Answer: set of government mandated criteria that
must be obtained for every patient
◉ medical decision making. Answer: physicians though process
◉ Scribes can.... Answer: document history, physician exam, results,
procedures. access and document laboratory and radiology findings.
locate and obtain PMHx, previous charts, past results.
◉ Scribes cannot.... Answer: partake in any activity that may affect
patient health, touch patients, handle bodily fluids, sign any charts,
give verbal orders or submit electronic orders.
◉ are physician assistants and nurse practitioners considered
medical providers?. Answer: YES
◉ T/F: The scribe can listen to a patient's heart and lungs as long as
it is for learning purposes and under the supervision of the
physician.. Answer: False
,◉ Lucy has been seen by Dr. Heart for the past 2 years. She is here
today for a routine appointment with Dr. Heart. Is Lucy a new or
established patient?. Answer: Established
◉ a patient made an appointment because she developed a rash a
few days ago. what type of visit would this be?. Answer: diagnostic
◉ diagnostic visits consist of. Answer: new problems, new
symptoms
◉ health management visits consist of. Answer: check-ups,
management visits
◉ a patient has an appointment for management of her diabetes.
what type of visit would this be?. Answer: health management
◉ who is the first person to speak with the patient after he/she is
place in a room?. Answer: Nurse/MA
◉ What are the meaningful use requirements the nurse/MA will
obtain?. Answer: Chief complaint; Vital signs (HR, BP, T, RR), Height,
weight, BMI; Smoking status
, ◉ What does H&P abbreviate and who performs this evaluation?.
Answer: history and physical, performed by the provider
◉ Is a differential diagnosis necessary for a health maintenance
visit?. Answer: nope.
◉ what information will be included in the patient's plan? give 3
examples.. Answer: F/U for specialist, instructions for lifestyle, F/U
for next routine appointment
◉ name the 8 elements of the HPI. Answer: Location, Quality,
Severity, Context, Timing, Duration, Associated signs and symptoms,
Modifying factors
◉ polydipsia. Answer: excessive thirst
◉ paresthesia. Answer: sensation of tingling or numbness
◉ anticoagulant. Answer: a drug that prevents blood clotting
◉ chronic illness. Answer: longer than 3 months
◉ if a patient has had respiratory symptoms for the past 5 weeks,
are the symptoms considered chronic?. Answer: No
MEDICAL SCRIBING CERTIFICATION TEST
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ pain vs tenderness. Answer: patients feeling vs physicians
assessment
◉ benign. Answer: normal, nothing of concern
◉ acute vs chronic. Answer: new onset vs long standing
◉ baseline. Answer: an individuals normal state of being
◉ ausculation. Answer: listening to sound with a stethoscope
◉ palpation. Answer: 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: main reason for the patients visit
◉ meaningful use. Answer: set of government mandated criteria that
must be obtained for every patient
◉ medical decision making. Answer: physicians though process
◉ Scribes can.... Answer: document history, physician exam, results,
procedures. access and document laboratory and radiology findings.
locate and obtain PMHx, previous charts, past results.
◉ Scribes cannot.... Answer: partake in any activity that may affect
patient health, touch patients, handle bodily fluids, sign any charts,
give verbal orders or submit electronic orders.
◉ are physician assistants and nurse practitioners considered
medical providers?. Answer: YES
◉ T/F: The scribe can listen to a patient's heart and lungs as long as
it is for learning purposes and under the supervision of the
physician.. Answer: False
,◉ Lucy has been seen by Dr. Heart for the past 2 years. She is here
today for a routine appointment with Dr. Heart. Is Lucy a new or
established patient?. Answer: Established
◉ a patient made an appointment because she developed a rash a
few days ago. what type of visit would this be?. Answer: diagnostic
◉ diagnostic visits consist of. Answer: new problems, new
symptoms
◉ health management visits consist of. Answer: check-ups,
management visits
◉ a patient has an appointment for management of her diabetes.
what type of visit would this be?. Answer: health management
◉ who is the first person to speak with the patient after he/she is
place in a room?. Answer: Nurse/MA
◉ What are the meaningful use requirements the nurse/MA will
obtain?. Answer: Chief complaint; Vital signs (HR, BP, T, RR), Height,
weight, BMI; Smoking status
, ◉ What does H&P abbreviate and who performs this evaluation?.
Answer: history and physical, performed by the provider
◉ Is a differential diagnosis necessary for a health maintenance
visit?. Answer: nope.
◉ what information will be included in the patient's plan? give 3
examples.. Answer: F/U for specialist, instructions for lifestyle, F/U
for next routine appointment
◉ name the 8 elements of the HPI. Answer: Location, Quality,
Severity, Context, Timing, Duration, Associated signs and symptoms,
Modifying factors
◉ polydipsia. Answer: excessive thirst
◉ paresthesia. Answer: sensation of tingling or numbness
◉ anticoagulant. Answer: a drug that prevents blood clotting
◉ chronic illness. Answer: longer than 3 months
◉ if a patient has had respiratory symptoms for the past 5 weeks,
are the symptoms considered chronic?. Answer: No
