Scribe America Outpatient Final Exam
Questions with Verified Answers
Subjective - Answer-from patient, HPI, ROS
Objective - Answer-from physician, PE, Lab, imaging
Pain - Answer-subjective from patient
Tenderness - Answer-objective from physician
Benign - Answer-Normal, nothing of concern
Acute - Answer-New onset, <3 months
Chronic - Answer-Long standing, >3 months
Baseline - Answer-An individual's normal state of being
Auscultation - Answer-Listening with a stethoscope (heart, lungs, abdomen)
Palpation - Answer-The act of pressing on an area (by a 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: Chief Complaint, 5 vital signs, height, weight, BMI, smoking status if
>13 y/o
Medical Decision Making - Answer-The physicians thought process
Mid-level provider - Answer-Nurse Practitioner(LNP) or Physician Assistant (PA) that
works under the supervision of a physician to diagnose and treat patients
Nurse or Medical Assistant - Answer-Records medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers medications,
assists with procedures
,Receptionist - Answer-Answers phone calls, schedules appointments, answers patient
questions, provides patient with summary of visit and written instructions from provider
at check-out, and organizes the patient's paperwork
Scribe - Answer-Documents the patient's visit on behalf of the physician
Scribes cannot - Answer-touch patients, partake in any activity that may affect patient
health, handle bodily fluids or specimens, sign or authenticate any chart or record, give
verbal orders or submit electronic orders
Are physician assistants and nurse practitioners considered medical providers? -
Answer-Yes, mid-level
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - Answer-False
What will the scribe document for the outpatient visit?
Important notes for past medical records
History & Physical
Laboratory and radiology results
Physician interpretation of XRs and EKGs
Assessment
Plan - Answer-All of the above
Types of Patients - Answer-New and Established
New patient - Answer-No previous record in the last 3 years, longer visit, detailed chart
Established patient - Answer-Previous records available from last 3 years, even if from
different physician in same building, shorter visit, concise chart
Types of Clinic visits - Answer-Diagnostic and Health Maintenance/Management
Diagnostic visit - Answer-acute problem, chief complaint = new symptom, goal is to
determine the cause of the problem and appropriate treatment, diagnose
Health Maintenance/Management visit - Answer-Chronic symptom, every 3-4 months,
chief complaint = management of chronic problem, goal is to assess progress of
ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? - Answer-Established
A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be? - Answer-Diagnostic
,A patient has an appointment for management of her diabetes. What type of visit would
this be? - Answer-Health Maintenance/Management
Clinic Flow - Answer-Check-in, Physician Evaluation, Orders & Results, Assessment &
Plan, Check-Out
Meaningful Use - Answer-Chief Complaint, 5 Vital Signs, Height, Weight, BMI, Smoking
Status (>13y/o)
Vital Signs - Answer-HR, BP, Pulse Ox, Temperature, Resp. Rate
Nurse/MA assessment - Answer-Confirm CC, review allergies/medications, brief past
medical history
Physician Evaluation - Answer-Review patient's medical record (a&p from last visit),
History and Physical (H&P), Differential Dx (only diagnostic)
Orders - Answer-Lab studies, imaging, procedures,
Results - Answer-May result during visit, probably in a few days
Assessment - Answer-list of Dx
Plan - Answer-Who to see, When to f/u, Instructions
Check-out - Answer-Home or ED, education on illness provided, schedule f/u
Who is the first person to speak with the patient after he/she is placed in a room? -
Answer-Nurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - Answer-5 Vital
(BP, HR, Temp, O2 sat, RR), BMI, height, weight, smoking, CC
What does H&P abbreviate and who performs this? - Answer-History & Physical, by the
physician
Is a differential diagnosis necessary for a health maintenance visit? - Answer-No
What Information will be included in the patient's plan? - Answer-Who to see, when to
see, and instructions
Name of doc system and online or paper? - Answer-NextGen, online
Sections of a chart - Answer-S (HPI and ROS), Hx (PMHx, SHx, FHx), O(PE, Orders
and Results), A (Assessment), P (plan)
, Patient complaint goes in - Answer-HPI or ROS (if HPI, goes in ROS)
The CBC shows anemia, where does this info go? - Answer-Results
The EKG shows Normal Sinus Rhythm, where does this info go? - Answer-Results
The pt came to the clinic for CP, where does this info go? - Answer-HPI and ROS
The pt came in for CP but also stubbed his toe, where does this info go? - Answer-ROS
if not mentioned in HPI
The pt is in no acute distress, where does this info go? - Answer-PE
The pt has suffered from HTN for many years, where does this info go? - Answer-PMHx
There is tenderness of the RUQ - Answer-PE
The pt's mother has heart disease - Answer-FHx
The diagnosis is upper respiratory infection, where does this info go? - Answer-
Assessment
The patient will be prescribed penicillin today, where does this info go? - Answer-Plan
Symptoms of a true allergy - Answer-rash, itching, swelling, or difficulty breathing, NOT
adverse reactions (nausea, etc)
Patient says High blood pressure - Answer-HTN
Patient says high cholesterol - Answer-HLD
Patient says thyroid problem - Answer-Hypothyroidism, sometimes hyperthyroidism
Patient says diabetes - Answer-DM
Patient says I only take pills for diabetes - Answer-NIDDM (type 2)
Patient says I take shots (insulin) for diabetes - Answer-IDDM (type 1)
Patient says heart disease - Answer-usually CAD
Patient says heart attack - Answer-MI and CAD
Patient says heart failure - Answer-CHF (Congestive Heart Failure)
Patient says irregular heartbeat - Answer-A-fib
