Scribe America Final Exam OP/ Scribe America OP Final
Exam Concept List 2 SETS COMPLIED WITH COMPLETE
SOLUTION UPDATED 2025/2026 NEW EDITION
Scribes CAN - Ans 1. Document the history, physical exam, results, procedures, and physician
consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpreta,ons of X-Rays and ECG's
Scribes CANNOT - Ans -touch pa,ents
-write orders or prescrip,ons
-give verbal orders
-partake in any ac,vity that may affect pa,ent health or outcome
-sign or authen,cate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC) - Ans the main reason for the pa,ent's visit
EMR / EHR - Ans Electronic Medical Record / Electronic Health Record
Subjec,ve - Ans feelings of the pa,ent
Objec,ve - Ans factual findings from the provider
,pain - Ans pa,ents feeling of discomfort
tenderness - Ans doctors finding of reproducible pain
acute - Ans New onset, likely concerning
chronic - Ans Long-standing, not of direct concern
new pa,ent (NP) - Ans a pa,ent that has never been seen at the clinic or was seen greater
than 3 years ago.
no previous records.
longer visits.
detailed chart.
established pa,ent (EP) - Ans a pa,ent that has been seen at the clinic by any provider within
the last 3 years.
previous records available.
shorter visits.
concise chart.
,Diagnos,c visit - Ans New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit - Ans Check-up,
Chief Complaint: Rou,ne physical or management of chronic problem(s),
and Goal is preventa,ve care and/or assessing progress of ongoing medical problems
History of Present Illness (HPI) - Ans The story and context of the Chief Complaint (subjec,ve)
Review of Systems (ROS) - Ans A head-to-toe list of posi,ves and nega,ves (subjec,ve)
Past history - Ans PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examina,on (PE) - Ans The physician's objec,ve findings
Orders and Results - Ans objec,ve evalua,on
Assessment - Ans current diagnoses
plan - Ans treatment plan and follow up
, high blood pressure - Ans Hypertension (HTN)
high cholesterol - Ans Hyperlipidemia (HLD)
diabetes - Ans Diabetes Mellitus (DM)
"I only take pills for my diabetes" - Ans Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes" - Ans Insulin Dependent Diabetes Mellitus (IDDM)
heart disease - Ans Coronary Artery Disease (CAD)
heart a=ack - Ans Myocardial Infarc,on (MI) and CAD
heart failure - Ans Conges,ve Heart Failure (CHF)
Irregular heartbeat - Ans Arrhythmia, Atrial Fibrilla,on (A-Fib)
Emphysema or Chronic Bronchi,s - Ans Chronic Obstruc,ve Pulmonary Disease (COPD)
Blood clot in lung - Ans Pulmonary Embolism (PE)
pneumonia or lung infec,on - Ans pneumonia (PNA)
reflux - Ans Gastroesophageal Reflux Disease (GERD)
Exam Concept List 2 SETS COMPLIED WITH COMPLETE
SOLUTION UPDATED 2025/2026 NEW EDITION
Scribes CAN - Ans 1. Document the history, physical exam, results, procedures, and physician
consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpreta,ons of X-Rays and ECG's
Scribes CANNOT - Ans -touch pa,ents
-write orders or prescrip,ons
-give verbal orders
-partake in any ac,vity that may affect pa,ent health or outcome
-sign or authen,cate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC) - Ans the main reason for the pa,ent's visit
EMR / EHR - Ans Electronic Medical Record / Electronic Health Record
Subjec,ve - Ans feelings of the pa,ent
Objec,ve - Ans factual findings from the provider
,pain - Ans pa,ents feeling of discomfort
tenderness - Ans doctors finding of reproducible pain
acute - Ans New onset, likely concerning
chronic - Ans Long-standing, not of direct concern
new pa,ent (NP) - Ans a pa,ent that has never been seen at the clinic or was seen greater
than 3 years ago.
no previous records.
longer visits.
detailed chart.
established pa,ent (EP) - Ans a pa,ent that has been seen at the clinic by any provider within
the last 3 years.
previous records available.
shorter visits.
concise chart.
,Diagnos,c visit - Ans New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit - Ans Check-up,
Chief Complaint: Rou,ne physical or management of chronic problem(s),
and Goal is preventa,ve care and/or assessing progress of ongoing medical problems
History of Present Illness (HPI) - Ans The story and context of the Chief Complaint (subjec,ve)
Review of Systems (ROS) - Ans A head-to-toe list of posi,ves and nega,ves (subjec,ve)
Past history - Ans PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examina,on (PE) - Ans The physician's objec,ve findings
Orders and Results - Ans objec,ve evalua,on
Assessment - Ans current diagnoses
plan - Ans treatment plan and follow up
, high blood pressure - Ans Hypertension (HTN)
high cholesterol - Ans Hyperlipidemia (HLD)
diabetes - Ans Diabetes Mellitus (DM)
"I only take pills for my diabetes" - Ans Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes" - Ans Insulin Dependent Diabetes Mellitus (IDDM)
heart disease - Ans Coronary Artery Disease (CAD)
heart a=ack - Ans Myocardial Infarc,on (MI) and CAD
heart failure - Ans Conges,ve Heart Failure (CHF)
Irregular heartbeat - Ans Arrhythmia, Atrial Fibrilla,on (A-Fib)
Emphysema or Chronic Bronchi,s - Ans Chronic Obstruc,ve Pulmonary Disease (COPD)
Blood clot in lung - Ans Pulmonary Embolism (PE)
pneumonia or lung infec,on - Ans pneumonia (PNA)
reflux - Ans Gastroesophageal Reflux Disease (GERD)
