SCRIBE AMERICA FINAL EXAM RETAKE ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES|AGRADE
What does "PHI" stand for? Expand the abbreviation. (Remember: do not include
any extra spaces before or after the term/phrase) - ANSWER: Protected Health
Information
What medical term describes the surgical removal of the gallbladder? (Remember:
when typing your answer, do not include any extra spaces before or after the
term/phrase. For example: Correct way "Good luck" vs incorrect " good luck ".) -
ANSWER: Cholecystectomy
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's 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
What is the medical abbreviation for the condition commonly described as, "reflux"?
- ANSWER: GERD
What medical term would best describe "the likely course or outcome of a disease"?
(Remember do not include spaces before or after your answer.) - 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 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: Chronologic Structure
Which of the following would be valid complications for CAD? (Select all that apply) -
ANSWER: MI
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? HINT: two words. Expand abbreviations. (Remember do not include
spaces before or after your answer.) - 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
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. (Remember do not include extra spaces before or after your
answer) - 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.
(Remember do not include spaces before or after your answer.) - ANSWER: Coronary
artery disease
CORRECT DETAILED ANSWERS WITH RATIONALES|AGRADE
What does "PHI" stand for? Expand the abbreviation. (Remember: do not include
any extra spaces before or after the term/phrase) - ANSWER: Protected Health
Information
What medical term describes the surgical removal of the gallbladder? (Remember:
when typing your answer, do not include any extra spaces before or after the
term/phrase. For example: Correct way "Good luck" vs incorrect " good luck ".) -
ANSWER: Cholecystectomy
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's 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
What is the medical abbreviation for the condition commonly described as, "reflux"?
- ANSWER: GERD
What medical term would best describe "the likely course or outcome of a disease"?
(Remember do not include spaces before or after your answer.) - 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 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: Chronologic Structure
Which of the following would be valid complications for CAD? (Select all that apply) -
ANSWER: MI
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? HINT: two words. Expand abbreviations. (Remember do not include
spaces before or after your answer.) - 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
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. (Remember do not include extra spaces before or after your
answer) - 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.
(Remember do not include spaces before or after your answer.) - ANSWER: Coronary
artery disease
