ScribeAmerica Outpatient Final Practice Questions and Answers | Latest 2025/ 2026 Update |100% Verified Elaborations | GRADED A

ScribeAmerica Outpatient Final Practice Questions and Answers | Latest 2025/ 2026 Update |100% Verified Elaborations | GRADED A Question: What will the scribe document for the outpatient visit? Answer: Important notes for past medical records History and Physical Laboratory and radiology results Physician Interpretation of XRs and EKGs Assessment and Plan Question: Who is the first person to speak with the patient after he/she is placed in the room? Answer: Nurse or MA Question: What are the meaningful use requirements the nurse or MA will obtain? Answer: Vital Signs (BP, RR, HR, T), Chief Complaint, Height, Weight, BMI, Smoking Status Question: What does H&P abbreviate and who performs this evaluation? Answer: History and Physical, physician Question: Is a differential diagnosis necessary for a health maintenance visit? No, only for a diagnostic visit Question: What information will be included in the patient's plan? Answer: Specialist follow-up, instructions for lifestyle and preventative care, routine follow-up Question: The CBC shows anemia Answer: Results Question: The EKG shows NSR Answer: Results Question: The pt came to the clinic for chest pain Answer: HPI/ROS Question: The pt also stubbed his toe last week Answer: HPI/ROS Question: The pt is in no acute distress Answer: Physical Exam Question: The pt has suffered from HTN for many years Answer: PMHx Question: Thee is tenderness of the RUQ Answer: PE Question: The pt's mother has heart disease Answer: FHX Question: The diagnosis is upper respiratory infection Answer: Assessment Question: The pt will be prescribed penicillin today Answer: Plan Question: What age would a family member's cardiac disease indicate an increased risk for similar heart disease in the pt? Answer: 55 y/o Question: What are three common general FHx your physician may ask about? Answer: HTN, CA, DM Question: Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx Answer: section? Yes Question: Why must smoking status be documented on every patient 13 years and older? Answer: Meaningful use requirements Question: HIPPA Rule 1 Answer: If a patient is not assigned to your doctor, do not touch the chart Question: HIPAA Rule 2 Answer: There is always someone watching Question: HIPAA Rule 3 Answer: Never share your username or password Question: HIPAA Rule 4 Answer: Your job does not belong on social media Question: HIPAA Rule 5 Answer: Ask yourself "Do I need to access this for my job?" Question: HIPAA Rule 6 Answer: Do not store any protected health information (PHI) on non-approved systems Question: HIPAA Rule 7 do not access family, friend or own medical record HIPAA Rule 8 No cell phones or pictures Question: What should you do before leaving your workstation for the cafeteria? Answer: Log out Question: What is the purpose of HIPAA? Answer: It is a body of laws designed to protect the private health information of patients across the country. Question: What does PHI stand for? Answer: Protected Health Information Question: Name three items that are considered PHI Answer: First or Last name, Date of birth, medical record number, the fact the patient was seen at the clinic Question: What is the purpose of HITECH? Answer: The Health Information Technology for Economic and Clinical Health Act addresses the privacy and security issues related to electronic transmission of health information. PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption. Question: Meaningful Use Objectives scribes help with 1. Up-to-date problem list 2. Demographics 3. Vital signs 4. Smoking status 5. Provide patient with a visit summary at check-out 6. Protect health information Question: Who enforces meaningful use programs? Answer: Centers for Medicare and Medicaid Services Question: What are three goals of the meaningful use program? 1. Safely integrate technology into healthcare 2. Improve pt care coordination and track data trends 3. Empower patients through increased communication and transparency Question: Give five in-house lab examples 1. Pregnancy test 2. INR check 3. Finger-stick blood glucose 4. Rapid strep test 5. Urine dip Question: What is a V-Code? Answer: A billing code for preventative care Question: What does CPT stand for? Answer: Current Procedural Terminology Question: Name non-reimbursable complaints Answer: follow-up, check-up, lab results, medication refill Question: Question: True/False: A level 4 is a "comprehensive" E&M level? Answer: True Question: Why is it important to memorize the elements needed for a level 4? Answer: To accurately reflect care given and to document to a high level and avoid E&M level downgrading. Question: How many HPI elements are needed for a new patient at level 4? Answer: 4 elements Question: How many ROS elements are needed for established level 4? Answer: 2 elements Question: True/False: Each diagnosis should be followed-up with at least one line-item in the plan? True Question: How is the plan formatted? Answer: Bullet points, numbers, or paragraph Question: The last bullet point in the plan should always be? Answer: the follow-up Question: Name three items you may include in a plan for Upper Respiratory Infection Answer: Alternate Tylenol/Motrin for pain Push Fluids Off school for two days Return in 1 week, sooner if worse Question: Name four items that can be included in a patient's plan: 1. Medication and treatment for each diagnosis 2. Prescriptions ordered today 3. Studies or tests ordered today 4. Follow-up with other healthcare professionals 5. Follow-up here for next appointment Question: Name three items that can be included in a plan for a pt with DM? Answer: Strictly follow metformin regimen as prescribed Continue adherence to diabetic diet If HbA1C has not improved next visit, will start insulin. Question: Name three items that can be included in a plan for a pt with HTN? Answer: Continue taking HCTZ as prescribed Continue BP log Will refill HCTZ today Follow-up in 3 months to check BP Question: True/False: The scribe should only include results that are new since the last visit? True Question: What three items should you include when summarizing a test result? Answer: Name of test, result of test, and why the test was ordered Question: Name four examples of lab results: Answer: CBC, lipid panel, urinalysis, pregnancy Question: Name four types of imaging studies: Answer: x-ray, CT, MRI, ultrasound (US) Question: What is the structure of a simple statement assessment? Answer: Age and sex, PMHx if relevant, and diagnosis Question: Name four items besides diagnosis that are included in a comprehensive summary assessment DDx if relevant, Summary of PMHx, summary of PE, Chief Complaint, Prognosis Question: True/False: A diagnosis or a differential diagnosis will always be listed in the assessment. TRUE Question: Name three things you can document in the General/Constitutional section for a normal peds exam? Alert, interactive, smiling, cries with tears Question: Why is it important that the patient is producing tears if crying? Answer: That can denote hydration Question: What does A&OX4 mean? Answer: Alert and oriented times 4 (person, place, time, or situation) Question: Name two signs of respiratory distress in a peds pt. Answer: Wheezing, stridor, nasal flares, retractions Question: Normal PE findings for Cardiovascular system Answer: RRR, heart sounds normal Question: Name normal PE findings for the pulmonary system No respiratory distress, CTAB (clear to auscultation bilaterally) Question: Name normal PE findings for the abdominal system Answer: Soft, non tender Question: Name normal PE findings for the neurological system Answer: A&OX4, normal speech, Non-focal neuro exam Question: Name abnormal PE findings for the skin system Answer: pallor, cyanosis, jaundice, diaphoresis, abrasion, laceration Question: Name abnormal PE findings for the psychiatric system Answer: tearful, anxious, depressed, paranoid, tangential speech Question: Name abnormal PE findings for the pulmonary system Answer: rales, wheezes, tachypnea, accessory muscle use, rhonchi, diminished breath sounds, mild/moderate/severe respiratory distress Question: CVA tenderness Answer: tenderness to percussion over a specific point in the flank where the kidneys lie (back) Question: Paraspinal tenderness muscular tenderness around the spine (back) Pitting Pedal edema Swelling of lower extremities, measured on a scale of trace to 4+ (musculoskeletal/ extremities) Question: Melena black Answer: stool on glove Question: Urticaria Answer: Hives/wheals (skin) Question: Somnolent Answer: unusually sleepiness (neurological) Question: 5/5 strength in bilateral upper extremities normal motor Answer: strength in the upper extremities (neurological) Question: 2+ patellar reflexes knee reflexes intact Answer: and normal (neurological) Question: EOM palsy shifting of the pupils back and forth horizontally - a sign of benign positional vertigo (neurological) Question: Name 10 body systems Answer: Constitutional, HEENT, cardiovascular, respiratory, pulmonary, neurological, gastrointestinal, genitourinary, musculoskeletal, skin, endocrine, hematologic/lymph, immunologic, psychiatric. Question: Name three types of HPI structures Answer: Single-complaint, multiple-complaint, and chronological Question: Name all 8 elements in a complete HPI Answer: Onset, timing, location, modifying factors, quality, severity, associated Sx, context Question: What is the Peak Expiratory Flow (PEF) measured in? Answer: Liters/minute Question: Name inhaled pharmacological management for Asthma Answer: pulmicort (steroid), advair, xopenex Question: What type of medication can treat CAD? Answer: ASA, NTG Question: How is CAD diagnosed? Answer: Cardiac Catheterization Question: Name the five risk factors for CAD Answer: HTN, HLD, DM, smoking, FHx55y/o Question: What PE findings most closely associate with asthma? Answer: Wheezing, shortness of breath Question: Name four risk factors of HLD Answer: Obesity, FHx, DM, EtOH abuse Question: What symptoms would a person with HLD experience? Answer: asymptomatic Question: What is the name of the drug group you should immediately associate with Answer: HLD? Statin Question: Why is High Density Lipoprotein called "good cholesterol?" Answer: Because it can remove plaque and recycle it back to the liver Question: What are insulin medications for DM? Answer: Humalog (short acting) and Lantus (long acting) Question: With a sliding scale insulin treatment, the pt adjusts the dosage of insulin base on Answer: Curren glucose levels Question: What does HCTZ sand for and what type of drug is it? Answer: Hydrochlorothiazide, diuretic Question: Can a patient be diagnosed with HTN without showing any Answer: symptoms? Yes Question: What can be caused by both HTN and DM? Answer: Renal failure, CHF, CAD Question: What is a comorbidity? Answer: The simultaneous onset of two chronic, complex diseases