Scribe America Final Exam – Q/A
What is the role of each person in the clinic? ✔️Ans - Mid-level: works
under the supervision of the physician to diagnose and treat patients
Nurse/MA: records medical histories and sx; monitors the patients, completes
meaningful use requirements, administers medication, assists with
procedures.
Receptionist: answers phone, schedules patient appointments, answers
patients questions, provides patient with summary of visit with instructions
from provider at checkout; organizes the patients paperwork's
Scribe: documents the patients visit on behalf of the physician.
What is the scope of a scribe? ✔️Ans - An unlicensed person performing
documentation and other non-clinical tasks under the direction of a
healthcare provider.
Are physician assistants and nurse practitioners considered medical
providers? ✔️Ans - No, they are mid-level provider.
T/F: The scribe can listen to a patient's heart and lungs as long as it is for
learning purposes and under supervision of the physician. ✔️Ans - FALSE
What will the scribe document for the outpatient visit? ✔️Ans - Document
the history, physical exam, results, procedures, assessment, and plan.
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a
routine appointment with Dr. Heart. Is Lucy a new or established patient?
✔️Ans - Established
A patient made an appointment because she developed a rash a few days ago.
What type of visit would this be? ✔️Ans - Diagnostic
A patient has an appointment for management of her diabetes. What type of
visit would this be? ✔️Ans - Health Management
Who is the first person to speak with the patient after is he/she is placed in a
room? ✔️Ans - Physician
, What are the meaningful use requirements the nurse/MA will obtain?
✔️Ans - Chief complaint, vital signs (HR, BP, T, RR), height, weight, BMI,
smoking status
What does H&P abbreviate and who perform this evaluation? ✔️Ans -
History and physical, physician evaluation
Is a differential diagnosis necessary for a health management visit? ✔️Ans -
No, only for diagnostic visit. (Possible Dx that may be causing the symptoms)
What information will be included in the patient's plan? Give three examples.
✔️Ans - Follow-up with specialist if necessary, instructions for lifestyle and
preventative care, and follow-up for next routine appointment.
At what age would a family member's cardiac disease indicate an increased
risk for similar heart disease in the patient? ✔️Ans - MI/CAD less than 55
y/o
What are three common general family histories your physician may ask
about? ✔️Ans - HTN, DM, CA
Would PMHx of chronic alcoholism belong in the SHx section as well as the
PMHx section? ✔️Ans - Social History (SHx)
Why must smoking status be documented on every patient 13 years and
older? ✔️Ans - Meaningful use requirement.
Name the three most common routes of administration of illicit drugs.
✔️Ans - oral, inhaled, injection
The patient's mother states, "The daycare called me to pick up Angela and her
brother because Angela had a fever." What are three items you can document
under social history for Angela? ✔️Ans - Mother (brought in and
caretaker), goes to Daycare, has a brother.
If a patient has had respiratory symptoms for the past 5 weeks, are the
symptoms considered chronic? ✔️Ans - No. An illness is typically classified
as chronic when it lasts longer than 3months.
What is the role of each person in the clinic? ✔️Ans - Mid-level: works
under the supervision of the physician to diagnose and treat patients
Nurse/MA: records medical histories and sx; monitors the patients, completes
meaningful use requirements, administers medication, assists with
procedures.
Receptionist: answers phone, schedules patient appointments, answers
patients questions, provides patient with summary of visit with instructions
from provider at checkout; organizes the patients paperwork's
Scribe: documents the patients visit on behalf of the physician.
What is the scope of a scribe? ✔️Ans - An unlicensed person performing
documentation and other non-clinical tasks under the direction of a
healthcare provider.
Are physician assistants and nurse practitioners considered medical
providers? ✔️Ans - No, they are mid-level provider.
T/F: The scribe can listen to a patient's heart and lungs as long as it is for
learning purposes and under supervision of the physician. ✔️Ans - FALSE
What will the scribe document for the outpatient visit? ✔️Ans - Document
the history, physical exam, results, procedures, assessment, and plan.
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a
routine appointment with Dr. Heart. Is Lucy a new or established patient?
✔️Ans - Established
A patient made an appointment because she developed a rash a few days ago.
What type of visit would this be? ✔️Ans - Diagnostic
A patient has an appointment for management of her diabetes. What type of
visit would this be? ✔️Ans - Health Management
Who is the first person to speak with the patient after is he/she is placed in a
room? ✔️Ans - Physician
, What are the meaningful use requirements the nurse/MA will obtain?
✔️Ans - Chief complaint, vital signs (HR, BP, T, RR), height, weight, BMI,
smoking status
What does H&P abbreviate and who perform this evaluation? ✔️Ans -
History and physical, physician evaluation
Is a differential diagnosis necessary for a health management visit? ✔️Ans -
No, only for diagnostic visit. (Possible Dx that may be causing the symptoms)
What information will be included in the patient's plan? Give three examples.
✔️Ans - Follow-up with specialist if necessary, instructions for lifestyle and
preventative care, and follow-up for next routine appointment.
At what age would a family member's cardiac disease indicate an increased
risk for similar heart disease in the patient? ✔️Ans - MI/CAD less than 55
y/o
What are three common general family histories your physician may ask
about? ✔️Ans - HTN, DM, CA
Would PMHx of chronic alcoholism belong in the SHx section as well as the
PMHx section? ✔️Ans - Social History (SHx)
Why must smoking status be documented on every patient 13 years and
older? ✔️Ans - Meaningful use requirement.
Name the three most common routes of administration of illicit drugs.
✔️Ans - oral, inhaled, injection
The patient's mother states, "The daycare called me to pick up Angela and her
brother because Angela had a fever." What are three items you can document
under social history for Angela? ✔️Ans - Mother (brought in and
caretaker), goes to Daycare, has a brother.
If a patient has had respiratory symptoms for the past 5 weeks, are the
symptoms considered chronic? ✔️Ans - No. An illness is typically classified
as chronic when it lasts longer than 3months.
