SCRIBE FINAL TEST QUESTIONS WITH
COMPLETE ANSWERS
T/F : Every HPI should begin with the age and sex of the patient. - Answer-True
T/F : Abbreviations are permitted in the HPI as long as they are approved. - Answer-
True
How would you document the onset of symptoms that began on Wednesday? - Answer-
Sx began, certain amount of days ago or exact date
What is the meaning of the word exacerbate? - Answer-worsened by
List the 5 vital signs?
______________________________
______________________________
______________________________
______________________________
______________________________ - Answer-Blood pressure
temperature
respiratory rate
heart rate
oxygen saturation
Who typically records the vital signs? - Answer-Nurse or MA
T/F : A scribe can take vital signs for a patient during downtime. - Answer-False
Name 5 body systems the physician can examine simply by observing (not touching)
the patient. - Answer-General, Eyes, Pulmonary, Skin, Neurological, Psychiatric
If the doctor palpates the patient's lower extremities, what is he looking for? - Answer-
Edema, distal pulses, tenderness
What does PERRL stand for and in which body system does it belong? - Answer-Pupils
equal round and reactive to light
List a normal exam finding for each of the following body systems:
, Cardiovascular: ________________________________________
Pulmonary: ___________________________________________
Abdominal: ___________________________________________
Musculoskeletal: _______________________________________
Neurological: __________________________________________ - Answer-RRR
no respiratory distress
soft
no edema
oriented and alert
List an abnormal exam finding for each of the following body systems:
Constitutional: ________________________________________
Skin: _______________________________________________ - Answer-1.
malnourished
2. jaundice
Name three findings you can document in the constitutional section for a normal
pediatric exam: - Answer-alert
playful
similing
Why is it incorrect to write A&OX3 on an infant neurological exam? - Answer-unable to
communicate also important to consider neurological development with respect to age
What are two signs of respiratory distress in a pediatric patient? - Answer-nasal flaring
stridor
T/F : When reviewing a previous visit, the physician is more likely to review the HPI than
the assessment and plan because the HPI gives more information. - Answer-F, the
document typically reviews the assessment because it is more comprehensive (contains
diagnosis and summary of visit)
what are 2 items besides the diagnosis that may be documented in the assessment? -
Answer-lab results
summary of HPI/PE
When summarizing test results, which items should be included? (Check all that apply)
Date of the test
COMPLETE ANSWERS
T/F : Every HPI should begin with the age and sex of the patient. - Answer-True
T/F : Abbreviations are permitted in the HPI as long as they are approved. - Answer-
True
How would you document the onset of symptoms that began on Wednesday? - Answer-
Sx began, certain amount of days ago or exact date
What is the meaning of the word exacerbate? - Answer-worsened by
List the 5 vital signs?
______________________________
______________________________
______________________________
______________________________
______________________________ - Answer-Blood pressure
temperature
respiratory rate
heart rate
oxygen saturation
Who typically records the vital signs? - Answer-Nurse or MA
T/F : A scribe can take vital signs for a patient during downtime. - Answer-False
Name 5 body systems the physician can examine simply by observing (not touching)
the patient. - Answer-General, Eyes, Pulmonary, Skin, Neurological, Psychiatric
If the doctor palpates the patient's lower extremities, what is he looking for? - Answer-
Edema, distal pulses, tenderness
What does PERRL stand for and in which body system does it belong? - Answer-Pupils
equal round and reactive to light
List a normal exam finding for each of the following body systems:
, Cardiovascular: ________________________________________
Pulmonary: ___________________________________________
Abdominal: ___________________________________________
Musculoskeletal: _______________________________________
Neurological: __________________________________________ - Answer-RRR
no respiratory distress
soft
no edema
oriented and alert
List an abnormal exam finding for each of the following body systems:
Constitutional: ________________________________________
Skin: _______________________________________________ - Answer-1.
malnourished
2. jaundice
Name three findings you can document in the constitutional section for a normal
pediatric exam: - Answer-alert
playful
similing
Why is it incorrect to write A&OX3 on an infant neurological exam? - Answer-unable to
communicate also important to consider neurological development with respect to age
What are two signs of respiratory distress in a pediatric patient? - Answer-nasal flaring
stridor
T/F : When reviewing a previous visit, the physician is more likely to review the HPI than
the assessment and plan because the HPI gives more information. - Answer-F, the
document typically reviews the assessment because it is more comprehensive (contains
diagnosis and summary of visit)
what are 2 items besides the diagnosis that may be documented in the assessment? -
Answer-lab results
summary of HPI/PE
When summarizing test results, which items should be included? (Check all that apply)
Date of the test
