SCRIBE AMERICA SCRIBE U FINAL EXAM QUESTIONS WITH
VERIRIED ACCURATE ANSWERS
Define SOAP - Answers -subjective, objective, assessment, plan
CC - Answers -chief complaint
what terms are important to have to make sure the provider is reimbursed - Answers -
discuss, management, evaluation
HPI - Answers -history of present illness (the story of the symptoms)
What are the 8 elements of the HPI? - Answers -Onset, Timing, Location, Quality,
Severity, Modifying Factors, Associated Symptoms, Context
Onset - Answers -when the symptoms began , never write days of the week, use 3
days ago, weeks ago, months ago
Modifying Factors - Answers -What makes it better? What makes it worse? (ex.
sleeping on my right side makes it better)
Timing - Answers -the frequency of the reported symptoms, constant, intermittent,
waxing and waning
Location - Answers -where the discomfort is coming from
quality - Answers -describing the pain, sharp, dull, aching, cramping
severity - Answers -how bad is the pain, mild, moderate, severe, on a scale of 1-10
associated symptoms (sx) - Answers -any other symptoms that accompany the
complaint
NAD - Answers -no acute distress
Define term and name body system it is under:
Cachectic , Emaciated - Answers -General , Constitutional malnourished
Define term and name body system it is under:
obtunded - Answers -General,
spaced out, in a stupor
Define term and name body system it is under:
AT/NC - Answers -Head,
Atraumatic / Normocephalic
, Define term and name body system it is under:
EOMI - Answers -Eyes,
Extra ocular muscles intact
Eyes are moving intact
Define term and name body system it is under:
Anicteric - Answers -Eyes
Without yellowing
Define term and name body system it is under:
Normal conjunctiva - Answers -Eyes
white under eyes
(normal)
Define term and name body system it is under:
PERRL - Answers -Eyes
pupils equal round and reactive to light
Define term and name body system it is under:
Anisocria - Answers -Eyes
two different sized pupils
Define term and name body system it is under:
EOM entrapment - Answers -Eyes
extra ocular muscle entrapment
lazy eye
Define term and name body system it is under:
Sclera Icterus - Answers -Eyes
yellowing in eyes
Define term and name body system it is under:
pale conjunctiva - Answers -Eyes
paleness of lower part of inner eye,
associated w/ anemia
Define term and name body system it is under:
Conjunctival injection / hyperemia - Answers -Eyes
redness in eyes, pink eye
Define term and name body system it is under:
TMs normal - Answers -Ear
tympanic membranes normal
Define term and name body system it is under:
VERIRIED ACCURATE ANSWERS
Define SOAP - Answers -subjective, objective, assessment, plan
CC - Answers -chief complaint
what terms are important to have to make sure the provider is reimbursed - Answers -
discuss, management, evaluation
HPI - Answers -history of present illness (the story of the symptoms)
What are the 8 elements of the HPI? - Answers -Onset, Timing, Location, Quality,
Severity, Modifying Factors, Associated Symptoms, Context
Onset - Answers -when the symptoms began , never write days of the week, use 3
days ago, weeks ago, months ago
Modifying Factors - Answers -What makes it better? What makes it worse? (ex.
sleeping on my right side makes it better)
Timing - Answers -the frequency of the reported symptoms, constant, intermittent,
waxing and waning
Location - Answers -where the discomfort is coming from
quality - Answers -describing the pain, sharp, dull, aching, cramping
severity - Answers -how bad is the pain, mild, moderate, severe, on a scale of 1-10
associated symptoms (sx) - Answers -any other symptoms that accompany the
complaint
NAD - Answers -no acute distress
Define term and name body system it is under:
Cachectic , Emaciated - Answers -General , Constitutional malnourished
Define term and name body system it is under:
obtunded - Answers -General,
spaced out, in a stupor
Define term and name body system it is under:
AT/NC - Answers -Head,
Atraumatic / Normocephalic
, Define term and name body system it is under:
EOMI - Answers -Eyes,
Extra ocular muscles intact
Eyes are moving intact
Define term and name body system it is under:
Anicteric - Answers -Eyes
Without yellowing
Define term and name body system it is under:
Normal conjunctiva - Answers -Eyes
white under eyes
(normal)
Define term and name body system it is under:
PERRL - Answers -Eyes
pupils equal round and reactive to light
Define term and name body system it is under:
Anisocria - Answers -Eyes
two different sized pupils
Define term and name body system it is under:
EOM entrapment - Answers -Eyes
extra ocular muscle entrapment
lazy eye
Define term and name body system it is under:
Sclera Icterus - Answers -Eyes
yellowing in eyes
Define term and name body system it is under:
pale conjunctiva - Answers -Eyes
paleness of lower part of inner eye,
associated w/ anemia
Define term and name body system it is under:
Conjunctival injection / hyperemia - Answers -Eyes
redness in eyes, pink eye
Define term and name body system it is under:
TMs normal - Answers -Ear
tympanic membranes normal
Define term and name body system it is under:
