SCRIBE AMERICA OP ACTUAL EXAM PAPER
2026 QUESTIONS WITH SOLUTIONS GRADED
A+
◉ 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:
False
◉ ** A patient underwent brain surgery to treat bleeding in the brain
from a stroke. What PSHx would you record into the chart? Answer:
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 complaints structure
◉ Which of the following is NOT a purpose of HITECH? Answer: - To
require patient accountability in paying for their health care visit
- 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
◉ 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 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
◉ * 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? (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
2026 QUESTIONS WITH SOLUTIONS GRADED
A+
◉ 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:
False
◉ ** A patient underwent brain surgery to treat bleeding in the brain
from a stroke. What PSHx would you record into the chart? Answer:
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 complaints structure
◉ Which of the following is NOT a purpose of HITECH? Answer: - To
require patient accountability in paying for their health care visit
- 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
◉ 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 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
◉ * 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? (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
