SCRIBE AMERICA FINAL EXAM 2 2026
CLINICAL DOCUMENTATION ASSESSMENT
STUDY GUIDE COMPLETE QUESTIONS AND
ANSWERS
◉ 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: select all
◉ What does HIPAA stand for? Answer: Health Insurance Portability
and Accountability Act
◉ What chronic condition would require diagnosis through fasting
blood glucose level of HbA1c? Answer: Diabetes
,◉ A patient states she had a productive cough for 4 days, and
yesterday she developed a fever. Would her fever be considered an
associated symptom for her productive cough? Why or why not?
Answer: Yes, because the fever started soon after the cough
◉ Which of the following would be documented in the objective
section of the SOAP note? Answer: -Interpretations/results
-Physical exam
-Orders
-Treatments
◉ HIPAA is a set of laws designed to _________ Answer: maintain
patient privacy and confidentiality
◉ What condition correctly describes "blood clot in lungs" Answer:
pulmonary embolism, PE
◉ Matching the following description with corresponding term.
Answer: MACRA- government health care initiative that focuses on
quality of car to improve patient outcomes.
MIPS- system of payment in which government finding is released if
specific quality measures are tracked
Quality Measures- site specific health criteria that are tracked
, ◉ Match the following scenario to the corresponding risk. Answer:
Low risk- patient with stable htn and no other comorbities
High risk- patient with acute exerbation of ESRD requiring
emergency dialysis
Moderate risk- asthmatic patient with accute acerbation that is
resolve in office with nebulizer treatment
◉ What chronic condition would require diagnosis through a lipid
panel? Answer: HLD
◉ Which of the following are considered non-reimbursable chief
complaints? Answer: -medication refill
-check up
-lab results
◉ Expand the following medical abbreviation. What does "CP" stand
for? Answer: Chest pain
◉ 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
CLINICAL DOCUMENTATION ASSESSMENT
STUDY GUIDE COMPLETE QUESTIONS AND
ANSWERS
◉ 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: select all
◉ What does HIPAA stand for? Answer: Health Insurance Portability
and Accountability Act
◉ What chronic condition would require diagnosis through fasting
blood glucose level of HbA1c? Answer: Diabetes
,◉ A patient states she had a productive cough for 4 days, and
yesterday she developed a fever. Would her fever be considered an
associated symptom for her productive cough? Why or why not?
Answer: Yes, because the fever started soon after the cough
◉ Which of the following would be documented in the objective
section of the SOAP note? Answer: -Interpretations/results
-Physical exam
-Orders
-Treatments
◉ HIPAA is a set of laws designed to _________ Answer: maintain
patient privacy and confidentiality
◉ What condition correctly describes "blood clot in lungs" Answer:
pulmonary embolism, PE
◉ Matching the following description with corresponding term.
Answer: MACRA- government health care initiative that focuses on
quality of car to improve patient outcomes.
MIPS- system of payment in which government finding is released if
specific quality measures are tracked
Quality Measures- site specific health criteria that are tracked
, ◉ Match the following scenario to the corresponding risk. Answer:
Low risk- patient with stable htn and no other comorbities
High risk- patient with acute exerbation of ESRD requiring
emergency dialysis
Moderate risk- asthmatic patient with accute acerbation that is
resolve in office with nebulizer treatment
◉ What chronic condition would require diagnosis through a lipid
panel? Answer: HLD
◉ Which of the following are considered non-reimbursable chief
complaints? Answer: -medication refill
-check up
-lab results
◉ Expand the following medical abbreviation. What does "CP" stand
for? Answer: Chest pain
◉ 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
