Scribe America Final Exam OP questions
and answers 2025\2026 A+ Grade
Scribes CAN
- correct answer 1. Document the history, physical exam, results, procedures, and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT
- correct answer -touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC)
- correct answer the main reason for the patient's visit
EMR / EHR
- correct answer Electronic Medical Record / Electronic Health Record
Subjective
- correct answer feelings of the patient
,Objective
- correct answer factual findings from the provider
pain
- correct answer patients feeling of discomfort
tenderness
- correct answer doctors finding of reproducible pain
acute
- correct answer New onset, likely concerning
chronic
- correct answer Long-standing, not of direct concern
new patient (NP)
- correct answer a patient that has never been seen at the clinic or was seen greater than 3 years ago.
no previous records.
longer visits.
detailed chart.
established patient (EP)
- correct answer a patient that has been seen at the clinic by any provider within the last 3 years.
previous records available.
shorter visits.
, concise chart.
Diagnostic visit
- correct answer New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit
- correct answer Check-up,
Chief Complaint: Routine physical or management of chronic problem(s),
and Goal is preventative care and/or assessing progress of ongoing medical problems
History of Present Illness (HPI)
- correct answer The story and context of the Chief Complaint (subjective)
Review of Systems (ROS)
- correct answer A head-to-toe list of positives and negatives (subjective)
Past history
- correct answer PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examination (PE)
- correct answer The physician's objective findings
Orders and Results
- correct answer objective evaluation
and answers 2025\2026 A+ Grade
Scribes CAN
- correct answer 1. Document the history, physical exam, results, procedures, and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT
- correct answer -touch patients
-write orders or prescriptions
-give verbal orders
-partake in any activity that may affect patient health or outcome
-sign or authenticate any chart or record
-handle bodily fluids or specimens
Chief Complaint (CC)
- correct answer the main reason for the patient's visit
EMR / EHR
- correct answer Electronic Medical Record / Electronic Health Record
Subjective
- correct answer feelings of the patient
,Objective
- correct answer factual findings from the provider
pain
- correct answer patients feeling of discomfort
tenderness
- correct answer doctors finding of reproducible pain
acute
- correct answer New onset, likely concerning
chronic
- correct answer Long-standing, not of direct concern
new patient (NP)
- correct answer a patient that has never been seen at the clinic or was seen greater than 3 years ago.
no previous records.
longer visits.
detailed chart.
established patient (EP)
- correct answer a patient that has been seen at the clinic by any provider within the last 3 years.
previous records available.
shorter visits.
, concise chart.
Diagnostic visit
- correct answer New problem,
chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management visit
- correct answer Check-up,
Chief Complaint: Routine physical or management of chronic problem(s),
and Goal is preventative care and/or assessing progress of ongoing medical problems
History of Present Illness (HPI)
- correct answer The story and context of the Chief Complaint (subjective)
Review of Systems (ROS)
- correct answer A head-to-toe list of positives and negatives (subjective)
Past history
- correct answer PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family)
Physical Examination (PE)
- correct answer The physician's objective findings
Orders and Results
- correct answer objective evaluation
