SCRIBE AMERICA FINAL EXAM 2 2026
MEDICAL SCRIBING CERTIFICATION TEST
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ What does "PHI" stand for? 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 in the chart? Answer:
Craniotomy
◉ A patients 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. 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 best to use in this scenario? Answer:
Multiple complaints structure?
◉ Which of the following is not a purpose of HITECH? Answer: -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.
-To require government accountability on health insurance plans
available in the market place.
-To require encryption when using technology to transmit patient
related 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: -Patient
arrival time
-percentage of time spent counseling
-percentage of time spent with physician vs with nurse/MA
-total time with the patient
-patient departure times
◉ 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:
MEDICAL SCRIBING CERTIFICATION TEST
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ What does "PHI" stand for? 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 in the chart? Answer:
Craniotomy
◉ A patients 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. 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 best to use in this scenario? Answer:
Multiple complaints structure?
◉ Which of the following is not a purpose of HITECH? Answer: -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.
-To require government accountability on health insurance plans
available in the market place.
-To require encryption when using technology to transmit patient
related 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: -Patient
arrival time
-percentage of time spent counseling
-percentage of time spent with physician vs with nurse/MA
-total time with the patient
-patient departure times
◉ 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:
