ScribeAmerica OP Final questions and
answers 2025\2026 A+ Grade
* What medical term describes the surgical removal of the gallbladder?
- correct answer cholecystectomy
What does "PHI" stand for? Expand the abbreviation.
- correct answer Protected Health Information
T/F. Sharing information about a case with family is allowed, as long as you are scribing with the
physician assigned to the case.
- correct answer False
** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you
record into the chart?
- correct answer craniotomy
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?
- correct answer Established
A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physician
discusses 4-5 different back stretching exercises that the patient can perform every morning and before
doing any heavy lifting. The discussion only takes 10 minutes of a 15 minute Established Patient visit.
Would your physician be able to bill counseling time on this patient?
- correct answer Yes
What medical term would best describe "the likely course or outcome of a disease"?
- correct answer Prognosis
, Which section of the chart should you document when you hear the following cue "what medical
problems do you have"?
- correct 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?
- correct answer Multiple complaints structure
Which of the following is NOT a purpose of HITECH?
- correct answer - To require patient accountability in paying for their health care visit
- To require government accountability on health insurance plans available in the market place
-To require equal access, opportunity, and affordability for health insurance plans by screening patient
health information
What medical term would describe a patient with a history of infection or inflammation of the liver?
- correct answer Hepatitis
For correct billing and reimbursement to go through, a counseling note requires documentation of the
following:
- correct answer - Total time with the patient
- Percentage of time spent counseling
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?
- correct answer Chronologic structure
Which of the following would be valid complications for CAD?
- correct answer MI
* 57 year old male patient presented with RLQ abdominal pain, which began 5 days ago. He states that
he was mowing the lawn when the pain began. Patient reports he took OTC Tylenol yesterday without
relief. There has been no nausea, vomiting or diarrhea.
- correct answer Yes, the HPI meets Level 4 billing criteria.
answers 2025\2026 A+ Grade
* What medical term describes the surgical removal of the gallbladder?
- correct answer cholecystectomy
What does "PHI" stand for? Expand the abbreviation.
- correct answer Protected Health Information
T/F. Sharing information about a case with family is allowed, as long as you are scribing with the
physician assigned to the case.
- correct answer False
** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you
record into the chart?
- correct answer craniotomy
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?
- correct answer Established
A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physician
discusses 4-5 different back stretching exercises that the patient can perform every morning and before
doing any heavy lifting. The discussion only takes 10 minutes of a 15 minute Established Patient visit.
Would your physician be able to bill counseling time on this patient?
- correct answer Yes
What medical term would best describe "the likely course or outcome of a disease"?
- correct answer Prognosis
, Which section of the chart should you document when you hear the following cue "what medical
problems do you have"?
- correct 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?
- correct answer Multiple complaints structure
Which of the following is NOT a purpose of HITECH?
- correct answer - To require patient accountability in paying for their health care visit
- To require government accountability on health insurance plans available in the market place
-To require equal access, opportunity, and affordability for health insurance plans by screening patient
health information
What medical term would describe a patient with a history of infection or inflammation of the liver?
- correct answer Hepatitis
For correct billing and reimbursement to go through, a counseling note requires documentation of the
following:
- correct answer - Total time with the patient
- Percentage of time spent counseling
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?
- correct answer Chronologic structure
Which of the following would be valid complications for CAD?
- correct answer MI
* 57 year old male patient presented with RLQ abdominal pain, which began 5 days ago. He states that
he was mowing the lawn when the pain began. Patient reports he took OTC Tylenol yesterday without
relief. There has been no nausea, vomiting or diarrhea.
- correct answer Yes, the HPI meets Level 4 billing criteria.
