SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
LATEST VERSION (VERSION A & B) 2025
What does "PHI" stand for? Expand the abbreviation -Correct Answer ✔protected health
information
What medical term describes the surgical removal of the gallbladder? -Correct Answer
✔cholecystectomy
T/F. Sharing information about a case with family is allowed, as long as you are scribing
with the physician assigned to the case -Correct Answer ✔False
A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering
for the PCP during this time. The patient has never been seen by the NP before. Is the
patient considered a new patient or an established patient? -Correct Answer
✔Established
What is the medical abbreviation for the condition commonly described as "reflux" -
Correct Answer ✔GERD
What medical term would best describe "the likely course or outcome of a disease?" -
Correct Answer ✔prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have?" -Correct Answer ✔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? -Correct
Answer ✔multiple complaints structure
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? -Correct Answer ✔chronological structure
Which of the following would be valid complications for CAD? (Select all that apply) -
Correct Answer ✔MI
11. What are the possible consequences of a HIPAA violation? (Select all that apply) -
Correct Answer ✔*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
, SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. -Correct Answer ✔Health
Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? Two words, expand the abbreviation. -Correct Answer ✔diabetes mellitus
A patient states she has had a productive cough for 4 days, and yesterday she
developed a fever. Would her fever be considered an associated symptom for her
productive cough? Why or why not? -Correct Answer ✔Yes, because the fever started
soon after the cough
15. Which of the following would be documented in the Objective section of the SOAP
note? (select all that apply) -Correct Answer ✔*Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to__________. (select the best option) -Correct
Answer ✔maintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood clot in the
lungs"? (Use the abbreviation form of the condition) -Correct Answer ✔PE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. -Correct Answer ✔HLD
Which of the following are considered non-reimbursable chief complaints? (Select all
that apply) -Correct Answer ✔*follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork and does
not know what medications he should be taking at home. He asks you to look up his
medical record when you go to your shift today, giving you verbal permission to access
his information. In this scenario, it is justifiable for you to use your EMR login to look up
the important patient information. -Correct Answer ✔False
A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic
condition should be included in their diagnosis today? Expand the abbreviation? -
Correct Answer ✔coronary artery disease
SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
LATEST VERSION (VERSION A & B) 2025
What does "PHI" stand for? Expand the abbreviation -Correct Answer ✔protected health
information
What medical term describes the surgical removal of the gallbladder? -Correct Answer
✔cholecystectomy
T/F. Sharing information about a case with family is allowed, as long as you are scribing
with the physician assigned to the case -Correct Answer ✔False
A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering
for the PCP during this time. The patient has never been seen by the NP before. Is the
patient considered a new patient or an established patient? -Correct Answer
✔Established
What is the medical abbreviation for the condition commonly described as "reflux" -
Correct Answer ✔GERD
What medical term would best describe "the likely course or outcome of a disease?" -
Correct Answer ✔prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have?" -Correct Answer ✔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? -Correct
Answer ✔multiple complaints structure
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? -Correct Answer ✔chronological structure
Which of the following would be valid complications for CAD? (Select all that apply) -
Correct Answer ✔MI
11. What are the possible consequences of a HIPAA violation? (Select all that apply) -
Correct Answer ✔*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
, SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
What does HIPAA stand for? Expand the abbreviation. -Correct Answer ✔Health
Insurance Portability and Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? Two words, expand the abbreviation. -Correct Answer ✔diabetes mellitus
A patient states she has had a productive cough for 4 days, and yesterday she
developed a fever. Would her fever be considered an associated symptom for her
productive cough? Why or why not? -Correct Answer ✔Yes, because the fever started
soon after the cough
15. Which of the following would be documented in the Objective section of the SOAP
note? (select all that apply) -Correct Answer ✔*Orders
*Interpretations/Results
*Physical Exam
HIPAA is a set of laws designed to__________. (select the best option) -Correct
Answer ✔maintain patient privacy and confidentiality
What is the medical abbreviation for the condition described as "blood clot in the
lungs"? (Use the abbreviation form of the condition) -Correct Answer ✔PE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. -Correct Answer ✔HLD
Which of the following are considered non-reimbursable chief complaints? (Select all
that apply) -Correct Answer ✔*follow-up
*check-up
*medication refill
*lab results
T/F. A family friend was recently evaluated for IDDM and lost his paperwork and does
not know what medications he should be taking at home. He asks you to look up his
medical record when you go to your shift today, giving you verbal permission to access
his information. In this scenario, it is justifiable for you to use your EMR login to look up
the important patient information. -Correct Answer ✔False
A patient is s/p angioplasty with stent and quadruple cardiac bypass. What chronic
condition should be included in their diagnosis today? Expand the abbreviation? -
Correct Answer ✔coronary artery disease
SCRIBEAMERICA OUTPATIENT FINAL EXAM 2
