SCRIBEAMERICA OP FINAL EXAM QUESTIONS 2025
What does "PHI" stand for? Expand the abbreviation - Answer -protected health
information
What medical term describes the surgical removal of the gallbladder? - 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 - 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? - Answer -Established
What is the medical abbreviation for the condition commonly described as "reflux" -
Answer -GERD
What medical term would best describe "the likely course or outcome of a disease?" -
Answer -prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have?" - 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? - 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? - Answer -chronological structure
Which of the following would be valid complications for CAD? (Select all that apply) -
Answer -MI
11. What are the possible consequences of a HIPAA violation? (Select all that apply) -
Answer -*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
, HIPAA is a set of laws designed to__________. (select the best option) - 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) - Answer -PE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. - Answer -HLD
Which of the following are considered non-reimbursable chief complaints? (Select all
that apply) - 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. - 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? -
Answer -coronary artery disease
A patient states that he has been having abdominal pain for the last three days, and it
varies between mild and severe. Which of the following would best describe the Timing?
- Answer -Waxing and waning
The patient reports a tenderness in their right upper abdomen that began 2 weeks ago.
Based on that information, do you document RUQ tenderness under the physical
exam? - Answer -No
What condition correctly describes "heart attack"? Use the abbreviated form of the
condition. - Answer -MI
A patient reportedly had their tonsils removed as a child. What PSHx would you record
into the chart? - Answer -tonsillectomy
What does HIPAA stand for? Expand the abbreviation. - 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. - Answer -diabetes mellitus
What does "PHI" stand for? Expand the abbreviation - Answer -protected health
information
What medical term describes the surgical removal of the gallbladder? - 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 - 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? - Answer -Established
What is the medical abbreviation for the condition commonly described as "reflux" -
Answer -GERD
What medical term would best describe "the likely course or outcome of a disease?" -
Answer -prognosis
Which section of the chart should you document when you hear the following cue "what
medical problems do you have?" - 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? - 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? - Answer -chronological structure
Which of the following would be valid complications for CAD? (Select all that apply) -
Answer -MI
11. What are the possible consequences of a HIPAA violation? (Select all that apply) -
Answer -*termination
*monetary fines to you and the hospital
*prison time
*lawsuit against you and the hospital
*violator is blacklisted from medical programs like medical, PA, or NP school
*scribe program cancellation
, HIPAA is a set of laws designed to__________. (select the best option) - 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) - Answer -PE
What chronic condition would require diagnosis through a lipid panel? Use the
abbreviation form. - Answer -HLD
Which of the following are considered non-reimbursable chief complaints? (Select all
that apply) - 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. - 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? -
Answer -coronary artery disease
A patient states that he has been having abdominal pain for the last three days, and it
varies between mild and severe. Which of the following would best describe the Timing?
- Answer -Waxing and waning
The patient reports a tenderness in their right upper abdomen that began 2 weeks ago.
Based on that information, do you document RUQ tenderness under the physical
exam? - Answer -No
What condition correctly describes "heart attack"? Use the abbreviated form of the
condition. - Answer -MI
A patient reportedly had their tonsils removed as a child. What PSHx would you record
into the chart? - Answer -tonsillectomy
What does HIPAA stand for? Expand the abbreviation. - 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. - Answer -diabetes mellitus
