©THESTAR 2024/2025 ALL RIGHTS RESERVED.
Scribe OP Final Exam Questions And
Correct Answers 100% Verified.
Subjective vs objective - Answer✔feeling vs. fact
pain vs tenderness - Answer✔patient's feeling vs. physician's assessment
benign - Answer✔Normal, nothing of concern
acute vs chronic - Answer✔new onset vs long standing
baseline - Answer✔An individual's normal state of being
Auscultation - Answer✔Listening with a stethoscope
Palpation - Answer✔The act of pressing on an area (by the physician)
inpatient - Answer✔Admitted to the hospital overnight
outpatient - Answer✔seen and sent home the same day
chief complaint - Answer✔the main reason for the patient's visit
meaningful use - Answer✔a set of government mandated criteria that must be obtained for every
patient
medical decision making - Answer✔the physician's thought process
give two examples of mid-level providers - Answer✔LPN, PA
what tasks can you complete as a scribe:
-document the history and physical exam while the physician performs them
-help a patient from his wheelchair to the exam chair
-locate previous results to show the provider
-sign the doctor's charts at the end of the day - Answer✔-document the history and physical
exam while the physician performs them
1|Page
, ©THESTAR 2024/2025 ALL RIGHTS RESERVED.
-locate previous results to show the provider
a chart for an established patient will be________ than the chart for a new patient -
Answer✔longer
in a diagnostic visit, the patient has a ________ complaint - Answer✔new
who typically obtains meaningful use requirements during patient check-in? -
Answer✔MA/nurse
H&P stands for _____ & ______ and is part of the ________ evaluation - Answer✔history &
physical, provider
name two items you will include in the patient's plan - Answer✔medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? -
Answer✔physical exam
"I have high blood pressure" --> you would write.... - Answer✔HTN
"I take shots for my diabetes" --> you would write.... - Answer✔IDDM
"My doctor says my heart is failing." --> you would write.... - Answer✔CHF
"I have acid reflux" --> you would write.... - Answer✔GERD
"I'm not pregnant. I have two children, but I miscarried my first pregnancy" --> you would
write.... - Answer✔G: 3/ P:2 / A:1
"I had a mini-stroke last year" --> you would write.... - Answer✔TIA
heart bypass surgery - Answer✔coronary artery bypass graft
breast removal surgery - Answer✔mastectomy
gallbladder removed surgery - Answer✔cholecystectomy
uterus removed surgery - Answer✔tubal ligation
neck artery cleaned surgery - Answer✔carotid endarterectomy
common general family histories that physicians frequently ask about - Answer✔HTN, DM, CA
SHx Living Circumstances - Answer✔lives alone, with family/friends, nursing home/assisted
living, hospice, homeless/shelter
Comorbidity - Answer✔the simultaneous presence of two chronic diseases or conditions in a
patient
etiology - Answer✔cause of disease
2|Page
, ©THESTAR 2024/2025 ALL RIGHTS RESERVED.
systole - Answer✔the phase of the heartbeat when the heart muscle contracts and pumps blood
from the chambers into the arteries.; pumping blood to the body
diastolic - Answer✔phase of the heartbeat during which muscle is relaxed and the heart fills with
blood
diuretic - Answer✔A substance that promotes the production of urine
paresthesia - Answer✔sensation of tingling or numbness
polydipsia - Answer✔excessive thirst
ischemia - Answer✔loss of blood supply to tissue
anticoagulant - Answer✔a drug that prevents blood clotting (blood thinner)
how long must a patient have a disease for it to be considered chronic? - Answer✔3 months
explain why patients with comorbidities are complex and give an example - Answer✔-the
treatment of one disease may affect or contradict the treatment of the second
-adverse drug interactions
-compounding symptoms may lead to poor compliance with treatment plan
-if both illnesses affect a specific organ system, the patient is at increased risk of organ failure
ex: might have DM and high BP
Complex patients often bill to a______level, so it's important to document thoroughly and
accurately - Answer✔higher
label the following BP readings as hypotensive, normal, pre-hypertensive, or hypertensive:
100/70
150/95
130/85 - Answer✔normal, hypertensive, pre-hypertensive
patients with HTN often become symptomatic when the HTN is chronic and worsening. Name
two symptoms a patient with severe HTN may experience: - Answer✔edema, HA, CP,
palpitations, blurred vision, epistaxis
giev three examples of non-pharmacological HTN management - Answer✔BP log, Decreased
ETOH intake, low-sodium diet, smoking cessation, exercise
abbreviation of hydrochlorothiazide - Answer✔HCTZ
the majority of diabetes patients have _______diabetes - Answer✔type II
3|Page
Scribe OP Final Exam Questions And
Correct Answers 100% Verified.
Subjective vs objective - Answer✔feeling vs. fact
pain vs tenderness - Answer✔patient's feeling vs. physician's assessment
benign - Answer✔Normal, nothing of concern
acute vs chronic - Answer✔new onset vs long standing
baseline - Answer✔An individual's normal state of being
Auscultation - Answer✔Listening with a stethoscope
Palpation - Answer✔The act of pressing on an area (by the physician)
inpatient - Answer✔Admitted to the hospital overnight
outpatient - Answer✔seen and sent home the same day
chief complaint - Answer✔the main reason for the patient's visit
meaningful use - Answer✔a set of government mandated criteria that must be obtained for every
patient
medical decision making - Answer✔the physician's thought process
give two examples of mid-level providers - Answer✔LPN, PA
what tasks can you complete as a scribe:
-document the history and physical exam while the physician performs them
-help a patient from his wheelchair to the exam chair
-locate previous results to show the provider
-sign the doctor's charts at the end of the day - Answer✔-document the history and physical
exam while the physician performs them
1|Page
, ©THESTAR 2024/2025 ALL RIGHTS RESERVED.
-locate previous results to show the provider
a chart for an established patient will be________ than the chart for a new patient -
Answer✔longer
in a diagnostic visit, the patient has a ________ complaint - Answer✔new
who typically obtains meaningful use requirements during patient check-in? -
Answer✔MA/nurse
H&P stands for _____ & ______ and is part of the ________ evaluation - Answer✔history &
physical, provider
name two items you will include in the patient's plan - Answer✔medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? -
Answer✔physical exam
"I have high blood pressure" --> you would write.... - Answer✔HTN
"I take shots for my diabetes" --> you would write.... - Answer✔IDDM
"My doctor says my heart is failing." --> you would write.... - Answer✔CHF
"I have acid reflux" --> you would write.... - Answer✔GERD
"I'm not pregnant. I have two children, but I miscarried my first pregnancy" --> you would
write.... - Answer✔G: 3/ P:2 / A:1
"I had a mini-stroke last year" --> you would write.... - Answer✔TIA
heart bypass surgery - Answer✔coronary artery bypass graft
breast removal surgery - Answer✔mastectomy
gallbladder removed surgery - Answer✔cholecystectomy
uterus removed surgery - Answer✔tubal ligation
neck artery cleaned surgery - Answer✔carotid endarterectomy
common general family histories that physicians frequently ask about - Answer✔HTN, DM, CA
SHx Living Circumstances - Answer✔lives alone, with family/friends, nursing home/assisted
living, hospice, homeless/shelter
Comorbidity - Answer✔the simultaneous presence of two chronic diseases or conditions in a
patient
etiology - Answer✔cause of disease
2|Page
, ©THESTAR 2024/2025 ALL RIGHTS RESERVED.
systole - Answer✔the phase of the heartbeat when the heart muscle contracts and pumps blood
from the chambers into the arteries.; pumping blood to the body
diastolic - Answer✔phase of the heartbeat during which muscle is relaxed and the heart fills with
blood
diuretic - Answer✔A substance that promotes the production of urine
paresthesia - Answer✔sensation of tingling or numbness
polydipsia - Answer✔excessive thirst
ischemia - Answer✔loss of blood supply to tissue
anticoagulant - Answer✔a drug that prevents blood clotting (blood thinner)
how long must a patient have a disease for it to be considered chronic? - Answer✔3 months
explain why patients with comorbidities are complex and give an example - Answer✔-the
treatment of one disease may affect or contradict the treatment of the second
-adverse drug interactions
-compounding symptoms may lead to poor compliance with treatment plan
-if both illnesses affect a specific organ system, the patient is at increased risk of organ failure
ex: might have DM and high BP
Complex patients often bill to a______level, so it's important to document thoroughly and
accurately - Answer✔higher
label the following BP readings as hypotensive, normal, pre-hypertensive, or hypertensive:
100/70
150/95
130/85 - Answer✔normal, hypertensive, pre-hypertensive
patients with HTN often become symptomatic when the HTN is chronic and worsening. Name
two symptoms a patient with severe HTN may experience: - Answer✔edema, HA, CP,
palpitations, blurred vision, epistaxis
giev three examples of non-pharmacological HTN management - Answer✔BP log, Decreased
ETOH intake, low-sodium diet, smoking cessation, exercise
abbreviation of hydrochlorothiazide - Answer✔HCTZ
the majority of diabetes patients have _______diabetes - Answer✔type II
3|Page
