Scribe U Practice Test

These questions are part of the practice quiz. Start practicing

• Which device is used for an acute exacerbation of CHF/COPD (severe)?
• Which statement about HIPAA is true?
• What is the purpose of the Review of Systems (ROS)?
• What does PE stand for in the Diagnosis section of the chart?
• In allergy documentation, the abbreviation NKDA stands for which phrase?
• A clinician documents pulses at four sites: wrist, top of the foot, neck, and back of the foot. Which mapping correctly pairs each site with its pulse as described?
• Which procedure is used to treat a pneumothorax (PTX)?
• What do the heart sounds S1 and S2 indicate?
• What is required to document a minor procedure in the chart?
• Which of the following is NOT considered a red flag phrase that prompts timely action?
• Which description matches Nasal Cannula (NC)?
• Which of the following would NOT be considered an example of PHI?
• Which test is commonly ordered to investigate thyroid disease?
• In medical notes, SOB stands for?
• In medical shorthand, PTX expands to which condition?
• Which term describes air in the pleural space on a chest radiograph?
• Which lab value is most commonly used to assess kidney function? (often with another marker)
• For every admitted patient, which documentation is essential?
• Which procedure is used to diagnose meningitis?
• In which section of the chart would you document the patient’s smoking history?
• Medical Decision Making (MDM) complexity takes into account which factors?
• Expand the abbreviation DNR.
• How would you document GPA for a patient who has been pregnant four times, has three living children, and is not currently pregnant?
• What does the acronym DOE stand for in a clinical context?
• A 43-year-old male presents with vomiting for 5 hours, hyperglycemia, and elevated ketones. Which diagnosis best explains his presentation?
• Which procedure is associated with sepsis?
• How is a 'new patient' different from an 'established patient' for E/M coding purposes?
• Which statement about the physical examination for Level 5 billing is correct?
• Which intervention is used for respiratory failure?
• What does the abbreviation 's/p' stand for in medical notes?
• Which diagnosis best matches chest pain that occurs when taking a deep breath?
• Which statement best distinguishes a sign from a symptom?
• Which team member helps the nurse and assists with procedures?
• Which abbreviation denotes a transient ischemic event?
• What is the medical term for infection of the gallbladder?
• PNA stands for which medical condition?
• DVT stands for?
• What does URI stand for?
• What does HIPAA regulate in healthcare?
• Which statement about 'Status Post' is true?
• Muffled heart sounds on examination most likely indicate which of the following?
• What is the standard abdominal exam sequence?
• Which abdominal quadrant is most commonly associated with appendicitis?
• CSF stands for?
• In the trauma scenario, which finding indicates back involvement or spinal stabilization on a backboard?
• What does GCS stand for?
• Which heart sound marks the start of systole?
• A patient with history of breast cancer treated with chemoradiation and mastectomy: does this meet Level 5 billing criteria for the chart section?
• In a patient with head trauma and loss of consciousness, which diagnosis is of greatest concern?
• The medical term for carotid artery cleaning is?
• What does CHF stand for?
• In a trauma patient described as lethargic with a cervical spine stabilization, which finding corresponds to the neurological system?
• Which test is used to diagnose atrial fibrillation?
• CBC stands for which diagnostic test?
• Which of these procedures qualifies as a critical care procedure requiring critical care time documentation?
• A Wood's lamp exam is used to document fluorescein uptake in which organ system?
• In the trauma scenario, which finding indicates neck involvement (stabilization with a hard collar)?
• In patient appearance documentation, what does NAD stand for?
• A productive cough that has gradually worsened over 4 weeks is most suggestive of which diagnosis?
• In the described ED privacy scenario, has George taken appropriate steps?
• Which system does a positive Romberg test primarily assess?
• Why is the abdominal exam performed in the order: inspection, auscultation, percussion, palpation?
• In the physical examination context, CVA stands for which anatomical landmark?
• A patient with dizziness described as room spinning, with tinnitus, nausea, vomiting, positive Romberg, and a negative head CT most likely has which diagnosis?
• How would you diagnose an abdominal aortic aneurysm (AAA)?
• GCS stands for what and what does it assess?
• True/False: All symptoms documented in the ROS are also documented in the HPI.
• What is the medical term for bright red blood in stools?
• Which diagnosis best matches burning chest pain?
• What does STAT indicate about an order?
• What does OPQRST help document in the HPI?
• Which diagnosis best matches chest pain described as sharp and stabbing that is triggered by exertion, described as a heavy pressure?
• What does E/M stand for in medical coding?
• Consent unobtainable due to clinical urgency during which procedure?
• Which medical term describes blood present in vomit?
• Which option best describes the Glasgow Coma Scale's purpose?
• Which term describes the appearance of bright red blood per rectum?
• A patient presents with abdominal pain localized to the right lower quadrant with fever; which diagnosis is most likely?
• Pleuritic chest pain is best described as chest pain that worsens with which activity?
• What does TIA stand for?
• Which term best describes patient-reported experience such as pain?
• Which test would be immediately ordered for a Cardiac Workup in the ED?
• When documenting chest pain, what sequence helps structure the HPI?
• Which team member administers breathing treatments and assists with managing a patient's airway?
• Pancreatic disease is typically located in which quadrant?
• Dyspepsia, the medical term for indigestion, is included in which ROS system?
• What does the term “return precautions” refer to in the Plan?
• Which test identifies atrial fibrillation on the rhythm strip?
• Which term describes a vascular change that temporarily deprives part of the brain of oxygen but does not cause lasting deficits?
• In trauma assessment, LOC stands for what?
• CVA expands to which term in medical shorthand?
• What is the purpose of a differential diagnosis?
• Which chart section would typically include information about the patient’s smoking history, alcohol use, and living situation?
• Which option best describes a sign in a clinical assessment?
• What condition is described by fertilized egg developing outside the uterus?
• A pregnant patient at 23 weeks presents with dysuria. Which diagnosis best fits this presentation?
• Which lab result is typically monitored closely to assess myocardial injury?
• Which of the following best represents a normal neurological exam finding?
• What does ETT stand for?
• If the combination of positive EKG and positive blood work is observed, what diagnosis is most likely?
• Which option lists the items commonly included in Social History?
• In OPQRST, which component documents when the symptom began?
• What does AAA stand for in medical terminology?
• IDDM stands for?
• Which statement correctly describes carotid endarterectomy?
• Which diagnosis is associated with SOB + Wheezing on Exam?
• Diverticulitis is most commonly associated with which abdominal quadrant?
• The abbreviation AKA commonly stands for which phrase?
• A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. What are the G, P, and A values, respectively?
• In the ED scenario describing diabetic ketoacidosis, which finding supports the diagnosis?
• What is “proxy history”?
• What is a GI cocktail?
• Which condition among the following would qualify for CCT?
• What does GERD stand for?
• Gallbladder disease presents in which quadrant?
• AMS stands for what?
• In obstetric shorthand, parity (P) refers to what?
• Which term describes the reason a procedure is performed?
• What is the minimum amount of time that critical care must be documented as provided?
• What does CPT stand for in medical billing?
• What condition does CAD refer to?
• What is a 'pertinent positive' in the history of present illness?
• What are 'pertinent negatives'?
• Which action can increase your provider's efficiency after charting the most?
• In the obstetric notation G4P3A1, what does the middle value represent?
• The Plan section typically includes which elements?
• BPV stands for?
• Which imaging modality is commonly used in an acute ED evaluation for chest symptoms?
• Which team member is a NP or PA who works under the supervision of a physician to diagnose and treat patients?
• What is the medical term for painful urination?
• The problem list helps guide management by tracking which items?
• In OPQRST, which element denotes where the symptom is felt?
• Which team member records medical histories, monitors the patient, starts IVs, administers medications, and assists with procedures?
• Which sequence is traditionally taught for the abdominal exam to prevent disturbing bowel sounds?
• In a patient with dyspnea, peripheral edema suggests dysfunction in which organs?
• In SOAP notes, what does the Subjective section contain?
• Which team member manages the ED patient flow?
• What abbreviation describes the scenario in which a patient declines a hospital stay and decides to go home instead?
• Which of the following is a factor that contributes to MDM complexity besides the number of problems?
• Which procedure is used for an abnormal heart rhythm?
• Which statement correctly defines a symptom?
• Which statement describes RA (room air) in oxygen delivery?
• After distal radial fracture, which option is an appropriate component of discharge planning?
• Which lab value is commonly used to screen for infection or inflammation?
• How do PMH and FH differ in a patient chart?
• How should a scribe handle medical judgments in the chart?
• Sepsis — Central Line Placement is the correct pairing; which pair is correct?
• Which items are essential in a medication order entry?
• During a shift with three patients—a productive cough for 4 weeks, abdominal pain localized to the right lower quadrant with fever, and urinary symptoms with positive dip—what are the most likely final diagnoses?
• Is it acceptable for a medical scribe to relay lab results and initiate an insulin drip under the physician's instruction in a busy emergency department?
• PNA expands to which medical condition?
• Which organ primarily filters blood and produces urine?
• What medical condition does the abbreviation PTX expand to?
• In a SOAP note, what goes in the Assessment section?
• Note that lungs are clear to auscultation bilaterally; which body system is being documented?
• Which procedure is used for cardiac arrest?
• What does EOMI stand for?
• What is the medical term for stones in the gallbladder?
• What does NTG stand for?
• Which action should a scribe avoid when documenting patient care?
• Which term describes an objective finding observed by the clinician?
• Which item would be included in a discharge disposition note after an ED visit?
• In the COPD presentation with a history of smoking, what does '3 ppd' refer to?
• What does ICD-10 stand for?
• Which term might describe a patch of increased density in the lung on a chest radiograph?
• What does NKDA stand for?
• Which diagnosis is associated with SOB + Unilateral Pedal Edema + Pleuritic Chest Pain?
• Which medication is important for meeting the chest pain core measure?
• Which option is an example of data used in MDM?
• Which item would belong in a psychiatric examination?
• Wrist fracture discharge note finding indicating intact distal function?
• An immune response that leads to rash, itching, swelling, or difficulty breathing describes which condition?
• What typical items are included in the Social History (SH)?
• Which description matches a Face Mask (FM) for oxygen delivery?
• What is time-based coding in evaluation and management (E/M) coding?
• What is a key safety step before finalizing a note?
• What is the primary screening test used to evaluate thyroid function?
• Which team member documents the patient's visit on behalf of the physician?
• Which item is typically included in a consult note when admitting a patient for treatment of bacterial meningitis?
• A patient with a cut on the left foot from glass two hours ago, with no tendon injury and intact circulatory, sensory, and motor function. What is the best diagnosis?
• Which statement about 'pertinent negatives' is most accurate?
• In the abdominal exam, which step follows auscultation?
• Tachycardia is best defined as what?
• Would fever be considered an associated symptom for a productive cough if it started after the cough? Choose the best justification.
• What medical term describes noticeable blood in the urine?
• A patient has negative EKG and negative blood work. Which diagnosis is most appropriate?
• Which description correctly defines endotracheal intubation?
• Which of the following is a non-modifiable cardiac risk factor for chest pain patients?
• Which term describes data that has been de-identified and is no longer PHI?
• Which description correctly defines a Non-rebreather mask in oxygen delivery?
• What does LBBB stand for?
• What is the best way to organize information in an HPI for a very complex patient who has had multiple recent hospital admissions and several significant complaints?
• Which combination of items is essential in a medication order entry?
• An irregularly irregular rhythm on cardiac examination is most commonly associated with which arrhythmia?
• Acute Exacerbation CHF/COPD (Severe) — CPAP/BiPAP is the correct pairing; which pair is correct?
• DP pulse refers to which artery?
• In a clinical note, what does the abbreviation PE stand for?
• Which diagnosis is associated with SOB + Bilateral Pedal Edema + Chest Pain?
• What does PHI stand for in privacy contexts?
• What is the medical term for coughing up blood?
• What is the function of a problem list in the patient chart?
• In clinical documentation, what does NAD indicate about a patient’s appearance?
• What are the three elements that determine the level of an Evaluation and Management (E/M) service?
• Which team member answers phone calls, pages other specialists/doctors, and organizes the patient's paperwork?
• Tachypnea is defined as which of the following?
• What does the abbreviation HTN stand for?
• A patient has negative EKG but positive blood work. Which diagnosis is most appropriate?
• In the MDM framework, which types of information contribute to the 'data' component?
• A 45-year-old male presents with sudden tearing chest pain radiating to the back and associated nausea. Which emergency conditions could explain these symptoms?
• What does COPD stand for?
• Which condition is described by translocation of a thrombus leading to dyspnea and hypoxia?
• How would you diagnose a pneumothorax?
• In a patient with constant tearing chest pain radiating to the back and nausea that began 1 hour ago, which feature of the presentation is most constant?
• If a patient signs a waiver allowing you to capture photo of their unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo?
• Which of the following findings would be most associated with integumentary assessment in the described patient?
• All symptoms documented in the History of Present Illness (HPI) are also documented in the Review of Systems (ROS).
• Which diagnosis is associated with SOB + Wheezing on Exam + Shx of 3 ppd?
• When is it permissible to share PHI without patient authorization?
• What is the primary purpose of the Plan section in a medical record?
• In time-based coding, which scenario provides the basis for the code level?
• Which element is included in EKG interpretation documentation?
• What term describes the patient's destination when the patient is discharged to home?