Scribe OP final exam Questions and answers 2025/2026 Graded A+
subjective vs objective - feeling vs. fact
pain vs tenderness - patient's feeling vs. physician's assessment
benign - Normal, nothing of concern
acute vs chronic - new onset vs long standing
baseline - An individual's normal state of being
Auscultation - Listening with a stethoscope
Palpation - The act of pressing on an area (by the physician)
inpatient - Admitted to the hospital overnight
outpatient - seen and sent home the same day
chief complaint - the main reason for the patient's visit
meaningful use - a set of government mandated criteria that must be obtained for every patient
medical decision making - the physician's thought process
give two examples of mid-level providers - 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 - -document the history and physical exam while the
physician performs them
-locate previous results to show the provider
a chart for an established patient will be________ than the chart for a new patient - longer
in a diagnostic visit, the patient has a ________ complaint - new
who typically obtains meaningful use requirements during patient check-in? - MA/nurse
H&P stands for _____ & ______ and is part of the ________ evaluation - history & physical, provider
name two items you will include in the patient's plan - medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? - physical exam
"I have high blood pressure" --> you would write.... - HTN
"I take shots for my diabetes" --> you would write.... - IDDM
"My doctor says my heart is failing." --> you would write.... - CHF
"I have acid reflux" --> you would write.... - GERD
, "I'm not pregnant. I have two children, but I miscarried my first pregnancy" --> you would write.... - G: 3/
P:2 / A:1
"I had a mini-stroke last year" --> you would write.... - TIA
heart bypass surgery - coronary artery bypass graft
breast removal surgery - mastectomy
gallbladder removed surgery - cholecystectomy
uterus removed surgery - tubal ligation
neck artery cleaned surgery - carotid endarterectomy
common general family histories that physicians frequently ask about - HTN, DM, CA
SHx Living Circumstances - lives alone, with family/friends, nursing home/assisted living, hospice,
homeless/shelter
Comorbidity - the simultaneous presence of two chronic diseases or conditions in a patient
etiology - cause of disease
systole - 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 - phase of the heartbeat during which muscle is relaxed and the heart fills with blood
diuretic - A substance that promotes the production of urine
subjective vs objective - feeling vs. fact
pain vs tenderness - patient's feeling vs. physician's assessment
benign - Normal, nothing of concern
acute vs chronic - new onset vs long standing
baseline - An individual's normal state of being
Auscultation - Listening with a stethoscope
Palpation - The act of pressing on an area (by the physician)
inpatient - Admitted to the hospital overnight
outpatient - seen and sent home the same day
chief complaint - the main reason for the patient's visit
meaningful use - a set of government mandated criteria that must be obtained for every patient
medical decision making - the physician's thought process
give two examples of mid-level providers - 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 - -document the history and physical exam while the
physician performs them
-locate previous results to show the provider
a chart for an established patient will be________ than the chart for a new patient - longer
in a diagnostic visit, the patient has a ________ complaint - new
who typically obtains meaningful use requirements during patient check-in? - MA/nurse
H&P stands for _____ & ______ and is part of the ________ evaluation - history & physical, provider
name two items you will include in the patient's plan - medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? - physical exam
"I have high blood pressure" --> you would write.... - HTN
"I take shots for my diabetes" --> you would write.... - IDDM
"My doctor says my heart is failing." --> you would write.... - CHF
"I have acid reflux" --> you would write.... - GERD
, "I'm not pregnant. I have two children, but I miscarried my first pregnancy" --> you would write.... - G: 3/
P:2 / A:1
"I had a mini-stroke last year" --> you would write.... - TIA
heart bypass surgery - coronary artery bypass graft
breast removal surgery - mastectomy
gallbladder removed surgery - cholecystectomy
uterus removed surgery - tubal ligation
neck artery cleaned surgery - carotid endarterectomy
common general family histories that physicians frequently ask about - HTN, DM, CA
SHx Living Circumstances - lives alone, with family/friends, nursing home/assisted living, hospice,
homeless/shelter
Comorbidity - the simultaneous presence of two chronic diseases or conditions in a patient
etiology - cause of disease
systole - 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 - phase of the heartbeat during which muscle is relaxed and the heart fills with blood
diuretic - A substance that promotes the production of urine
