Scribe Final Exam Question 2025/2026 Graded A+
For correct billing and reimbursement to go through, a counseling note requires
documentation of the following: - Total time with the patient
Percentage of the 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? - Chronologic Structure
Which of the following would be valid complications for CAD? - MI
Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a
NEW patient:
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. -
Yes, the HPI meets Level 4 billing criteria
What are the possible consequences of a HIPAA violation? - Lawsuit against you and
the hospital
Monetary fines to you and the hospital
Scribe program cancellation
Termination
Prison time
Violator is blacklisted from medical programs like Medical, PA, or NP school
What does HIPAA stand for? Expand the abbreviation. - Health Insurance Portability &
Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? - 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? - Yes, because the fever started soon after the
cough
Which of the following would be documented in the Objective section of the SOAP
note? - Interpretations/results
orders
treatments
PE
HIPAA is a set of laws designed to - maintain patient privacy and confidentiality
, What condition correctly describes "blood clot in the lungs"? (Use abbreviation) - PE
Matching the following description with the corresponding term. - MACRA = government
healthcare initiative that focuses on quality of care to improve patient outcomes
MIPS = system of payment in which government funding is released if specific quality
measures are tracked
Quality Measures = site specific health criteria that are tracked
Match the following scenario to the corresponding risk. - Moderate risk = asthmatic
patient with acute acerbation that is resolved in office with nebulizer treatment
High risk = patient with acute exerbation of ESRD requiring emergency dialysis
Low risk = patient with stable HTN and no other comordibities
What chronic condition would require diagnosis through a lipid panel? (abbrev) - HLD
Which of the following are considered non-reimbursable chief complaints? - Medication
refill
lab results
follow up
check uo
What does "CP" stand for? - Chest Pain
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. - F
What condition correctly describes "dangerous infection of the appendix"? - appendicitis
An elderly male patient has a history of an enlarged prostate. What PMHx would you
record into the chart? (abbrev) - BPH
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.) - Coronary Artery
Disease
A patient states that he has been having abdominal pain for the last three days, and it
varies between mild and severe. Which of the following would best describe the Timing?
- Waxing and waning
Which of the following would be included in a Problem List? - Pyelonephritis, resolved
Nephrolithiasis, stable
For correct billing and reimbursement to go through, a counseling note requires
documentation of the following: - Total time with the patient
Percentage of the 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? - Chronologic Structure
Which of the following would be valid complications for CAD? - MI
Read the following HPI and verify whether this HPI meets Level 4 billing criteria for a
NEW patient:
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. -
Yes, the HPI meets Level 4 billing criteria
What are the possible consequences of a HIPAA violation? - Lawsuit against you and
the hospital
Monetary fines to you and the hospital
Scribe program cancellation
Termination
Prison time
Violator is blacklisted from medical programs like Medical, PA, or NP school
What does HIPAA stand for? Expand the abbreviation. - Health Insurance Portability &
Accountability Act
What chronic condition would require diagnosis through fasting blood glucose level or
HbA1c? - 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? - Yes, because the fever started soon after the
cough
Which of the following would be documented in the Objective section of the SOAP
note? - Interpretations/results
orders
treatments
PE
HIPAA is a set of laws designed to - maintain patient privacy and confidentiality
, What condition correctly describes "blood clot in the lungs"? (Use abbreviation) - PE
Matching the following description with the corresponding term. - MACRA = government
healthcare initiative that focuses on quality of care to improve patient outcomes
MIPS = system of payment in which government funding is released if specific quality
measures are tracked
Quality Measures = site specific health criteria that are tracked
Match the following scenario to the corresponding risk. - Moderate risk = asthmatic
patient with acute acerbation that is resolved in office with nebulizer treatment
High risk = patient with acute exerbation of ESRD requiring emergency dialysis
Low risk = patient with stable HTN and no other comordibities
What chronic condition would require diagnosis through a lipid panel? (abbrev) - HLD
Which of the following are considered non-reimbursable chief complaints? - Medication
refill
lab results
follow up
check uo
What does "CP" stand for? - Chest Pain
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. - F
What condition correctly describes "dangerous infection of the appendix"? - appendicitis
An elderly male patient has a history of an enlarged prostate. What PMHx would you
record into the chart? (abbrev) - BPH
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.) - Coronary Artery
Disease
A patient states that he has been having abdominal pain for the last three days, and it
varies between mild and severe. Which of the following would best describe the Timing?
- Waxing and waning
Which of the following would be included in a Problem List? - Pyelonephritis, resolved
Nephrolithiasis, stable
