SCRIBEAMERICA OUTPATIENT CORE EXAM 2026 MAIN
QUESTIONS AND ANSWERS SURE A+
✔✔In which format is the plan typically given? - ✔✔bulleted list
✔✔emaciated - ✔✔cachectic
✔✔widespread, over a large area - ✔✔diffuse
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
General/Constitutional - ✔✔Do they look like they're in pain?
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
Eyes - ✔✔Are the sclera yellow?
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
Pulmonary - ✔✔Are they breathing comfortably?
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
Neurologic - ✔✔Are they answering questions appropriately?
✔✔What is one tool used to evaluate the eyes? - ✔✔PERRL
✔✔PERRL - ✔✔Pupils are equal, round and reactive to light
✔✔HIPAA - ✔✔Health Insurance Portability and Accountability Act
✔✔What is meaningful use? - ✔✔a set of government mandated criteria that must be
obtained for every patient
✔✔What is meaningful use enforced by? - ✔✔CMS, Centers for Medicare and Medicaid
Services
✔✔Objective - ✔✔facts
✔✔benign - ✔✔nothing of concern
, ✔✔baseline - ✔✔normal
✔✔inpatient - ✔✔admitted to the hospital overnight
✔✔Chief Complaint - ✔✔the main reason for the pt's visit
✔✔Medical Decision Making - ✔✔physician's thought process
✔✔Two mid level providers? - ✔✔NP, PA
✔✔Can a scribe document history, results, procedures, and touch patients? - ✔✔No
✔✔Who enters home medications and drug allergies into the chart? - ✔✔MA
✔✔High Blood Pressure - ✔✔HTN
✔✔High Cholesterol - ✔✔HLD
✔✔Thyroid Problem - ✔✔Hypothyroidism or Hyperthyroidism
✔✔Diabetes - ✔✔DM
✔✔"I only take pills for my diabetes" - ✔✔Non Insulin Dependent Diabetes Mellitus
✔✔"I take shots for my diabetes" - ✔✔Insulin Dependent Diabetes Mellitus
✔✔Heart Disease - ✔✔CAD
✔✔Heart Attack - ✔✔MI
✔✔CHF - ✔✔congestive heart failure
✔✔Irregular Heartbeat - ✔✔A-Fib
✔✔Murmur - ✔✔Heart Murmur
✔✔Episodes of abnormally fast/racing heartbeat - ✔✔SVT
✔✔Emphysema, Chronic Bronchitis - ✔✔COPD
✔✔PNA - ✔✔pneumonia
QUESTIONS AND ANSWERS SURE A+
✔✔In which format is the plan typically given? - ✔✔bulleted list
✔✔emaciated - ✔✔cachectic
✔✔widespread, over a large area - ✔✔diffuse
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
General/Constitutional - ✔✔Do they look like they're in pain?
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
Eyes - ✔✔Are the sclera yellow?
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
Pulmonary - ✔✔Are they breathing comfortably?
✔✔For each of the following exam systems, name something the doctor can observe
with an external examination, without touching or listening with a stethoscope?
Neurologic - ✔✔Are they answering questions appropriately?
✔✔What is one tool used to evaluate the eyes? - ✔✔PERRL
✔✔PERRL - ✔✔Pupils are equal, round and reactive to light
✔✔HIPAA - ✔✔Health Insurance Portability and Accountability Act
✔✔What is meaningful use? - ✔✔a set of government mandated criteria that must be
obtained for every patient
✔✔What is meaningful use enforced by? - ✔✔CMS, Centers for Medicare and Medicaid
Services
✔✔Objective - ✔✔facts
✔✔benign - ✔✔nothing of concern
, ✔✔baseline - ✔✔normal
✔✔inpatient - ✔✔admitted to the hospital overnight
✔✔Chief Complaint - ✔✔the main reason for the pt's visit
✔✔Medical Decision Making - ✔✔physician's thought process
✔✔Two mid level providers? - ✔✔NP, PA
✔✔Can a scribe document history, results, procedures, and touch patients? - ✔✔No
✔✔Who enters home medications and drug allergies into the chart? - ✔✔MA
✔✔High Blood Pressure - ✔✔HTN
✔✔High Cholesterol - ✔✔HLD
✔✔Thyroid Problem - ✔✔Hypothyroidism or Hyperthyroidism
✔✔Diabetes - ✔✔DM
✔✔"I only take pills for my diabetes" - ✔✔Non Insulin Dependent Diabetes Mellitus
✔✔"I take shots for my diabetes" - ✔✔Insulin Dependent Diabetes Mellitus
✔✔Heart Disease - ✔✔CAD
✔✔Heart Attack - ✔✔MI
✔✔CHF - ✔✔congestive heart failure
✔✔Irregular Heartbeat - ✔✔A-Fib
✔✔Murmur - ✔✔Heart Murmur
✔✔Episodes of abnormally fast/racing heartbeat - ✔✔SVT
✔✔Emphysema, Chronic Bronchitis - ✔✔COPD
✔✔PNA - ✔✔pneumonia
