SCRIBE FINAL | 100 QUESTIONS AND ANSWERS | 2026
UPDATE | WITH COMPLETE SOLUTION
What medical term describes the surgical removal of the gallbladder? Word
Answer - Cholecystectomy
What does "PHI" stand for? Expand the abbreviation Answer - Protected
Health Information
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 - F
A patient underwent brain surgery to treat bleeding in the brain from a stroke.
What PSHx would you record into the chart? Answer - ***NOT Hemorrhagic
CVA
Craniotomy for hemorrhagic CVA
OR Craniotomy??
A patient's PCP is on vacation. The patient is scheduled to see the NP who is
covering for the PCP during this time. The patient has never been seen by the
NP before. Is this patient considered a new patient or an established patient?
Answer - Established
A patient is diagnosed with back strain caused by heavy lifting. As part of the
treatment, the physician discusses 4-5 different back stretching exercises that
,the patient can perform every morning and before doing any heavy lifting. The
discussion only takes 10 minutes of a 15 minute Established Patient visit.
Would your physician be able to bill counseling time on this patient? Answer -
Yes
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 Complaint structure
Which of the following is NOT a purpose of HITECH? Answer - To require
government accountability on health insurance plans available in the market
place
To require equal access, opportunity, and affordability for health insurance
plans by screening patient health information
To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or
inflammation of the liver? Answer - Hepatitis
For correct billing and reimbursement to go through, a counseling note
requires documentation of the following: Answer - Total time with the patient
Percentage of the time spent counseling
, 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 - Chronologic Structure
Which of the following would be valid complications for CAD? Answer - MI
Read the following HPI and verify whether this HPI meets Level 4 billing criteria
for a NEW patient:
57 year old male patient presented with RLQ abdominal pain, which began 5
days ago. He states that he was mowing the lawn when the pain began. Patient
reports he took OTC Tylenol yesterday without relief. There has been no
nausea, vomiting or diarrhea. Answer - Yes, the HPI meets Level 4 billing
criteria
What are the possible consequences of a HIPAA violation? Answer - Lawsuit
against you and the hospital
Monetary fines to you and the hospital
Scribe program cancellation
Termination
Prison time
Violator is blacklisted from medical programs like Medical, PA, or NP school
What does HIPAA stand for? Expand the abbreviation. Answer - Health
Insurance Portability & Accountability Act
What chronic condition would require diagnosis through fasting blood glucose
level or HbA1c? Answer - Diabetes Mellitus
UPDATE | WITH COMPLETE SOLUTION
What medical term describes the surgical removal of the gallbladder? Word
Answer - Cholecystectomy
What does "PHI" stand for? Expand the abbreviation Answer - Protected
Health Information
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 - F
A patient underwent brain surgery to treat bleeding in the brain from a stroke.
What PSHx would you record into the chart? Answer - ***NOT Hemorrhagic
CVA
Craniotomy for hemorrhagic CVA
OR Craniotomy??
A patient's PCP is on vacation. The patient is scheduled to see the NP who is
covering for the PCP during this time. The patient has never been seen by the
NP before. Is this patient considered a new patient or an established patient?
Answer - Established
A patient is diagnosed with back strain caused by heavy lifting. As part of the
treatment, the physician discusses 4-5 different back stretching exercises that
,the patient can perform every morning and before doing any heavy lifting. The
discussion only takes 10 minutes of a 15 minute Established Patient visit.
Would your physician be able to bill counseling time on this patient? Answer -
Yes
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 Complaint structure
Which of the following is NOT a purpose of HITECH? Answer - To require
government accountability on health insurance plans available in the market
place
To require equal access, opportunity, and affordability for health insurance
plans by screening patient health information
To require patient accountability in paying for their health care visit
What medical term would describe a patient with a history of infection or
inflammation of the liver? Answer - Hepatitis
For correct billing and reimbursement to go through, a counseling note
requires documentation of the following: Answer - Total time with the patient
Percentage of the time spent counseling
, 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 - Chronologic Structure
Which of the following would be valid complications for CAD? Answer - MI
Read the following HPI and verify whether this HPI meets Level 4 billing criteria
for a NEW patient:
57 year old male patient presented with RLQ abdominal pain, which began 5
days ago. He states that he was mowing the lawn when the pain began. Patient
reports he took OTC Tylenol yesterday without relief. There has been no
nausea, vomiting or diarrhea. Answer - Yes, the HPI meets Level 4 billing
criteria
What are the possible consequences of a HIPAA violation? Answer - Lawsuit
against you and the hospital
Monetary fines to you and the hospital
Scribe program cancellation
Termination
Prison time
Violator is blacklisted from medical programs like Medical, PA, or NP school
What does HIPAA stand for? Expand the abbreviation. Answer - Health
Insurance Portability & Accountability Act
What chronic condition would require diagnosis through fasting blood glucose
level or HbA1c? Answer - Diabetes Mellitus
