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SCRIBEAMERICA OUTPATIENT FINAL 203 2026 CLINICAL DOCUMENTATION ASSESSMENT STUDY GUIDE COMPLETE QUESTIONS AND ANSWERS

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SCRIBEAMERICA OUTPATIENT FINAL 203 2026 CLINICAL DOCUMENTATION ASSESSMENT STUDY GUIDE COMPLETE QUESTIONS AND ANSWERS

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SCRIBEAMERICA OUTPATIENT FINAL 203 2026
FINAL ASSESSMENT PAPER HEALTH RECORD
ACCURACY COMPREHENSIVE QUESTIONS
AND ANSWERS VERIFIED A+

◉ 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


◉ 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:
chronological structure


◉ Which of the following would be valid complications for CAD?
(Select all that apply) Answer: MI


◉ 11. 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
*scribe program cancellation


◉ What does HIPAA stand for? Expand the abbreviation. Answer:
Health Insurance Portability and Accountability Act


◉ What chronic condition would require diagnosis through fasting
blood glucose level or HbA1c? Two words, expand the abbreviation.
Answer: diabetes mellitus


◉ A patient states she has 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


◉ 15. Which of the following would be documented in the Objective
section of the SOAP note? (select all that apply) Answer: *Orders
*Interpretations/Results
*Physical Exam


◉ HIPAA is a set of laws designed to__________. (select the best
option) Answer: maintain patient privacy and confidentiality

, ◉ What is the medical abbreviation for the condition described as
"blood clot in the lungs"? (Use the abbreviation form of the
condition) Answer: PE


◉ What chronic condition would require diagnosis through a lipid
panel? Use the abbreviation form. Answer: HLD


◉ Which of the following are considered non-reimbursable chief
complaints? (Select all that apply) Answer: *follow-up
*check-up
*medication refill
*lab results


◉ 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


◉ A patient is s/p angioplasty with stent and quadruple cardiac
bypass. What chronic condition should be included in their
diagnosis today? Expand the abbreviation? Answer: coronary artery
disease

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