10/06/2025, 15:49 ScribeAmerica OP Final COMPLETE EXAM SET 2025 |QUESTIONS AND ANSWERS | 100% ACCURATE Flashcards | Quizlet
ScribeAmerica OP Final COMPLETE EXAM SET
2025 |QUESTIONS AND ANSWERS | 100%
ACCURATE
Save
Terms in this set (231)
New Patient No previous records, longer visit, detailed chart
Previous records available from last 3 years, shorter
established patient
visit, concise chart
New problem, chief complaint: new symptom, goal is
Diagnostic visit to determine the cause of the problem and
appropriate treatment
check up, CC: routine physical or management of
health management chronic problems, goal is preventative care and/or
assessing progress of ongoing medical problems
1. Check-in
2. Physician Evaluation
Clinic Flow 3. Orders & Results
4. Assessment & Plan
5. Check-out
chief complaint
vital signs
Quality Measures
height, weight, BMI
Smoking Status
What goes in the History HPI, ROS, PE
and Physical (H&P)
https://quizlet.com/1053073242/scribeamerica-op-final-complete-exam-set-2025-questions-and-answers-100-accurate-flash-cards/?new 1/18
,10/06/2025, 15:49 ScribeAmerica OP Final COMPLETE EXAM SET 2025 |QUESTIONS AND ANSWERS | 100% ACCURATE Flashcards | Quizlet
DDx differential diagnosis
Patient says high blood Hypertension (HTN)
pressure
Patient says high Hyperlipidemia (HLD)
cholesterol
Patient says thyroid Usually Hypothyroidism, sometimes Hyperthyroidism
problem
Patient says diabetes Diabetes Mellitus (DM)
Patient says "I only take Non-Insulin Dependent Diabetes Mellitus (NIDDM)
pills for my diabetes"
Patient says "I take shots Insulin Dependent Diabetes Mellitus (IDDM)
for my diabetes"
Patient says heart disease Coronary Artery Disease (CAD)
Patient says heart attack Myocardial Infarction (MI) and CAD
Patient says heart failure Congestive Heart Failure (CHF)
Patient says Irregular arrhythmia
heartbeat
Patient says murmur heart murmur
Patient says episodes of supraventricular tachycardia (SVT)
abnormally fast/racing
heartbeat
Patient says asthma asthma
Patient says Chronic Obstructive Pulmonary Disease (COPD)
Emphysema/Chronic
Bronchitis
Patient says blood clot in Pulmonary Embolism (PE)
lung
Patient says pneumonia Pneumonia (PNA)
Patient says reflux Gastroesophageal Reflux Disease (GERD)
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, 10/06/2025, 15:49 ScribeAmerica OP Final COMPLETE EXAM SET 2025 |QUESTIONS AND ANSWERS | 100% ACCURATE Flashcards | Quizlet
Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis pancreatitis
Patient says hepatitis Hepatitis A, B, or C
Patient says diverticulitis Diverticulitis
Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis
Patient says irritable Irritable Bowel Syndrome (IBS)
bowel
Patient says bladder Urinary Tract Infection (UTI)
infection
Patient says kidney Pyelonephritis (Pyelo)
infection
Patient says kidney stones renal calculi
Chronic Renal Failure (CRF) or End Stage Renal
Patient says I'm on dialysis
Disease (ESRD) on dialysis
Patient says enlarged Benign Prostate Hypertrophy (BPH)
prostate
Gravida Total number of time the patient has been pregnant
number of pregnancies reaching viable gestational
Para
age (23 weeks) that the patient has had
Abortus total number of miscarriages or elective abortions
patient says brain bleed Hemorrhagic CVA
(stroke)
Patient says stroke Cerebrovascular Accident (CVA)
Patient says mini-stroke Transient Ischemic Attack (TIA)
Patient says seizures Seizure disorder/Epilepsy
Patient says bipolar bipolar disorder
Patient says schizophrenia schizophrenia
Patient says I drink a lot ETOH abuse or alcoholism
https://quizlet.com/1053073242/scribeamerica-op-final-complete-exam-set-2025-questions-and-answers-100-accurate-flash-cards/?new 3/18
ScribeAmerica OP Final COMPLETE EXAM SET
2025 |QUESTIONS AND ANSWERS | 100%
ACCURATE
Save
Terms in this set (231)
New Patient No previous records, longer visit, detailed chart
Previous records available from last 3 years, shorter
established patient
visit, concise chart
New problem, chief complaint: new symptom, goal is
Diagnostic visit to determine the cause of the problem and
appropriate treatment
check up, CC: routine physical or management of
health management chronic problems, goal is preventative care and/or
assessing progress of ongoing medical problems
1. Check-in
2. Physician Evaluation
Clinic Flow 3. Orders & Results
4. Assessment & Plan
5. Check-out
chief complaint
vital signs
Quality Measures
height, weight, BMI
Smoking Status
What goes in the History HPI, ROS, PE
and Physical (H&P)
https://quizlet.com/1053073242/scribeamerica-op-final-complete-exam-set-2025-questions-and-answers-100-accurate-flash-cards/?new 1/18
,10/06/2025, 15:49 ScribeAmerica OP Final COMPLETE EXAM SET 2025 |QUESTIONS AND ANSWERS | 100% ACCURATE Flashcards | Quizlet
DDx differential diagnosis
Patient says high blood Hypertension (HTN)
pressure
Patient says high Hyperlipidemia (HLD)
cholesterol
Patient says thyroid Usually Hypothyroidism, sometimes Hyperthyroidism
problem
Patient says diabetes Diabetes Mellitus (DM)
Patient says "I only take Non-Insulin Dependent Diabetes Mellitus (NIDDM)
pills for my diabetes"
Patient says "I take shots Insulin Dependent Diabetes Mellitus (IDDM)
for my diabetes"
Patient says heart disease Coronary Artery Disease (CAD)
Patient says heart attack Myocardial Infarction (MI) and CAD
Patient says heart failure Congestive Heart Failure (CHF)
Patient says Irregular arrhythmia
heartbeat
Patient says murmur heart murmur
Patient says episodes of supraventricular tachycardia (SVT)
abnormally fast/racing
heartbeat
Patient says asthma asthma
Patient says Chronic Obstructive Pulmonary Disease (COPD)
Emphysema/Chronic
Bronchitis
Patient says blood clot in Pulmonary Embolism (PE)
lung
Patient says pneumonia Pneumonia (PNA)
Patient says reflux Gastroesophageal Reflux Disease (GERD)
https://quizlet.com/1053073242/scribeamerica-op-final-complete-exam-set-2025-questions-and-answers-100-accurate-flash-cards/?new 2/18
, 10/06/2025, 15:49 ScribeAmerica OP Final COMPLETE EXAM SET 2025 |QUESTIONS AND ANSWERS | 100% ACCURATE Flashcards | Quizlet
Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis pancreatitis
Patient says hepatitis Hepatitis A, B, or C
Patient says diverticulitis Diverticulitis
Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis
Patient says irritable Irritable Bowel Syndrome (IBS)
bowel
Patient says bladder Urinary Tract Infection (UTI)
infection
Patient says kidney Pyelonephritis (Pyelo)
infection
Patient says kidney stones renal calculi
Chronic Renal Failure (CRF) or End Stage Renal
Patient says I'm on dialysis
Disease (ESRD) on dialysis
Patient says enlarged Benign Prostate Hypertrophy (BPH)
prostate
Gravida Total number of time the patient has been pregnant
number of pregnancies reaching viable gestational
Para
age (23 weeks) that the patient has had
Abortus total number of miscarriages or elective abortions
patient says brain bleed Hemorrhagic CVA
(stroke)
Patient says stroke Cerebrovascular Accident (CVA)
Patient says mini-stroke Transient Ischemic Attack (TIA)
Patient says seizures Seizure disorder/Epilepsy
Patient says bipolar bipolar disorder
Patient says schizophrenia schizophrenia
Patient says I drink a lot ETOH abuse or alcoholism
https://quizlet.com/1053073242/scribeamerica-op-final-complete-exam-set-2025-questions-and-answers-100-accurate-flash-cards/?new 3/18
