SCRIBEAMERICA FINAL EXAM MEDICAL SCRIBING
COURSE 2025/2026 | VERIFIED QUESTIONS AND
ANSWERS GRADED A+ | CLINICAL DOCUMENTATION &
PATIENT CARE STUDY GUIDE | GUARANTEED SUCCESS
What does TIA stand for? - CORRECT ANSWER - transient ischemic attack
A 43 y/o male presents to the ED with vomiting that began 5 hours ago. He has
a history of Type II DM and is s/p right BKA. On objective evaluation it is
found that he is hyperglycemic and has elevated ketones and so he will be
admitted for DKA. Match the details to the correct section of the chart. -
CORRECT ANSWER - Onset: 5 hours ago
Disposition: admit
ED Course: hyperglycemia and elevated ketones
CC: vomiting
PMHx: Type II DM
Diagnosis: DKA
PSHx: right BKA
Match the following description to the appropriate team member. - CORRECT
ANSWER - Scribe: Documents the patient's visits on behalf of the physician
Unit Secretary: Answers phone calls, pages other specialists/ doctors, and
organizes the patient's paperwork
ED Nurse: Records medical histories, symptoms, monitors the patient, starts
IVs, administers mediations, and assists with procedures
ED Tech: Helps the nurse and assists with procedures
,RT: Administers "breathing treatments" and assists with managing a patient's
airway
Mis-Level Provider: NP or PA that works under the supervision of a physician
to diagnose and treat patients
Charge Nurse: Manages the ED patient flow
T/F. It is the middle of the day. Your provider is busy dealing with a critical ill
patient and during this time the ED Strats to pick up tase as more patients arrive.
While your provider is prepping the critical patient for a procedure, she asks
you to look up the CBC result on another patient. You quickly look up the
information on your laptop and tell the physician that the labs came back
normal except for a blood glucose level of 356, so your provider subsequently
asks you to tell the nurse to start that patient on an insulin drip. You locate the
nurse and relay the message. This scenario is acceptable and within the bounds
of your scribe scope. - CORRECT ANSWER - False
A patient is seen in the emergency department complaining of dysuria and tells
you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI.
Which of the following would be the best diagnosis? - CORRECT ANSWER -
acute urinary tract infection in pregnancy, 2nd trimester
A patient cut his left foot on a piece of glass two hours ago and is seen in the
emergency department to have sutures placed. The doctor tells you there is no
tendon injury and circulatory, sensory and motor is intact. What is the best
diagnosis for his complaint? - CORRECT ANSWER - Uncomplicated
laceration of the left foot - initial encounter
What does AMS stand for? - CORRECT ANSWER - altered mental status
What does GCS stand for? - CORRECT ANSWER - glasgow coma scale
What does DNR stand for? - CORRECT ANSWER - do not resuscitate
, What does AAA stand for? - CORRECT ANSWER - abdominal aortic
aneurysm
What does PE stand for in the diagnosis section of the chart? - CORRECT
ANSWER - pulmonary embolism
What does DP stand for in "DP pulse"? - CORRECT ANSWER - dorsalis
pedis
What does DVT stand for? - CORRECT ANSWER - deep vein thrombosis
What does NTG stand for? - CORRECT ANSWER - nitroglycerin
What does URI stand for? - CORRECT ANSWER - upper respiratory
infection
What does CHF stand for? - CORRECT ANSWER - congestive heart failure
What does s/p stand for? - CORRECT ANSWER - status post
What does GERD stand for? - CORRECT ANSWER - gastroesophageal
reflux disease
What does EOMI stand for? - CORRECT ANSWER - extraocular movements
intact
What does DOE stand for? - CORRECT ANSWER - dyspnea on exertion
COURSE 2025/2026 | VERIFIED QUESTIONS AND
ANSWERS GRADED A+ | CLINICAL DOCUMENTATION &
PATIENT CARE STUDY GUIDE | GUARANTEED SUCCESS
What does TIA stand for? - CORRECT ANSWER - transient ischemic attack
A 43 y/o male presents to the ED with vomiting that began 5 hours ago. He has
a history of Type II DM and is s/p right BKA. On objective evaluation it is
found that he is hyperglycemic and has elevated ketones and so he will be
admitted for DKA. Match the details to the correct section of the chart. -
CORRECT ANSWER - Onset: 5 hours ago
Disposition: admit
ED Course: hyperglycemia and elevated ketones
CC: vomiting
PMHx: Type II DM
Diagnosis: DKA
PSHx: right BKA
Match the following description to the appropriate team member. - CORRECT
ANSWER - Scribe: Documents the patient's visits on behalf of the physician
Unit Secretary: Answers phone calls, pages other specialists/ doctors, and
organizes the patient's paperwork
ED Nurse: Records medical histories, symptoms, monitors the patient, starts
IVs, administers mediations, and assists with procedures
ED Tech: Helps the nurse and assists with procedures
,RT: Administers "breathing treatments" and assists with managing a patient's
airway
Mis-Level Provider: NP or PA that works under the supervision of a physician
to diagnose and treat patients
Charge Nurse: Manages the ED patient flow
T/F. It is the middle of the day. Your provider is busy dealing with a critical ill
patient and during this time the ED Strats to pick up tase as more patients arrive.
While your provider is prepping the critical patient for a procedure, she asks
you to look up the CBC result on another patient. You quickly look up the
information on your laptop and tell the physician that the labs came back
normal except for a blood glucose level of 356, so your provider subsequently
asks you to tell the nurse to start that patient on an insulin drip. You locate the
nurse and relay the message. This scenario is acceptable and within the bounds
of your scribe scope. - CORRECT ANSWER - False
A patient is seen in the emergency department complaining of dysuria and tells
you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI.
Which of the following would be the best diagnosis? - CORRECT ANSWER -
acute urinary tract infection in pregnancy, 2nd trimester
A patient cut his left foot on a piece of glass two hours ago and is seen in the
emergency department to have sutures placed. The doctor tells you there is no
tendon injury and circulatory, sensory and motor is intact. What is the best
diagnosis for his complaint? - CORRECT ANSWER - Uncomplicated
laceration of the left foot - initial encounter
What does AMS stand for? - CORRECT ANSWER - altered mental status
What does GCS stand for? - CORRECT ANSWER - glasgow coma scale
What does DNR stand for? - CORRECT ANSWER - do not resuscitate
, What does AAA stand for? - CORRECT ANSWER - abdominal aortic
aneurysm
What does PE stand for in the diagnosis section of the chart? - CORRECT
ANSWER - pulmonary embolism
What does DP stand for in "DP pulse"? - CORRECT ANSWER - dorsalis
pedis
What does DVT stand for? - CORRECT ANSWER - deep vein thrombosis
What does NTG stand for? - CORRECT ANSWER - nitroglycerin
What does URI stand for? - CORRECT ANSWER - upper respiratory
infection
What does CHF stand for? - CORRECT ANSWER - congestive heart failure
What does s/p stand for? - CORRECT ANSWER - status post
What does GERD stand for? - CORRECT ANSWER - gastroesophageal
reflux disease
What does EOMI stand for? - CORRECT ANSWER - extraocular movements
intact
What does DOE stand for? - CORRECT ANSWER - dyspnea on exertion
