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Quizzes > Health & Medicine

Medical Scribe Practice Test: 15 Questions to Sharpen Your Skills

Quick scribe test to check documentation and terminology skills. Instant results.

Editorial: Review CompletedCreated By: Calis MichaelUpdated Aug 24, 2025
Difficulty: Moderate
Questions: 20
Learning OutcomesStudy Material
Colorful paper art depicting elements related to Medical Scribe Exam Practice Quiz

This medical scribe practice test helps you review clinical documentation, basic terminology, and charting conventions with 15 multiple-choice questions. Use your results to spot gaps and build speed for real-world note taking. For deeper prep, try the medical terminology practice test, strengthen shortcuts with a medical abbreviation quiz, or expand skills with a medical transcription practice test.

Which section of a clinical note is best for documenting the patient's own words about their primary concern?
Chief Complaint
Plan
Past Medical History
Assessment
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In HIPAA-compliant documentation, which of the following is an acceptable way to reference a patient on a whiteboard in a shared area?
Use medical record number and diagnosis
Use full name and date of birth with diagnosis
Use first name and last initial only, without diagnosis
Use room number and full name with procedure
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Which abbreviation is unsafe and should be avoided in medical documentation?
U for units
q6h
PRN
PO
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Which term describes pain that starts suddenly and has a short duration?
Chronic
Refractory
Indolent
Acute
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Which measurements are used to calculate BMI in the chart?
Height and weight
Temperature and weight
Pulse and blood pressure
Respiratory rate and SpO2
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In a SOAP note, where does the physical examination belong?
Plan
Objective
Assessment
Subjective
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Which of the following should be included when documenting a laceration repair procedure?
Location, length, anesthesia, technique, suture type, and number
Nurse assignment schedule
Physician's years of experience
Patient's insurance copay
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Which imaging result phrase indicates no acute fracture on X-ray?
No acute osseous abnormality
Free intraperitoneal air
Diffuse cardiomegaly noted
Air-fluid levels present
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When documenting a stroke alert, which symptom onset detail is most critical?
Last known well time
Family history of cancer
Tetanus vaccination date
Primary care provider name
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Which ROS system is most appropriate for documenting dysuria and frequency?
Musculoskeletal
Integumentary
Endocrine
Genitourinary
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Which documentation is appropriate for a patient with Type 2 diabetes using insulin?
Diabetes, unspecified
Type 2 diabetes mellitus, insulin use: yes
Hyperglycemia, rule out
Type 1 diabetes by history
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Which statement about correcting an error in the EHR is best practice?
Email IT to remove the entry
Print and shred the page
Overwrite the text so the original is not visible
Use an addendum or correction function; do not delete original content
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Which element supports 2023 outpatient E/M medical decision making for data complexity?
Patient's employment status
Provider's years in practice
Independent interpretation of a test by the physician
Number of staff present
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Which documentation detail is required for time-based billing when counseling dominates the visit?
Patient satisfaction score
Number of diagnoses listed
Total time spent and that counseling/coordination of care dominated the visit with topics addressed
Only start and stop times
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Which ICD-10-CM code type is used to document the reason for a patient encounter diagnosis?
HCPCS Level II supply code
Diagnosis code from ICD-10-CM
Procedure code from CPT
NDC package code
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Which documentation best supports a diagnosis of community-acquired pneumonia?
Wheezing only, normal CXR
Fever, cough, focal crackles on exam, new infiltrate on CXR
Nonproductive cough, normal vitals, normal CXR
Sore throat, normal CXR, clear lungs
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What is the correct documentation practice for a critical lab value call from the lab?
Document only the value without time
Record value, time notified, person notifying, provider notified, and actions taken
Delete the lab and re-order it
Ask the patient to call back later
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Which component is required to document shared decision making for imaging in low-risk chest pain?
Nurse's note copied forward
Provider's personal opinion only
Billing code justification only
Risks and benefits discussed, alternatives, and patient preferences noted
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For a procedure note on moderate sedation, which detail must be documented?
Dietary preferences
Family history of migraines
Radiology room temperature
Pre-sedation assessment, intra-procedure monitoring, medications, and post-recovery status
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Which phrase correctly documents the presence of rales at the lung bases?
Bibasilar crackles present
Diffuse wheezes only
No adventitious sounds
Lungs CTA bilaterally
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Learning Outcomes

  1. Apply accurate medical terminology in clinical documentation.
  2. Identify key patient information during charting.
  3. Demonstrate efficient electronic health record navigation.
  4. Analyse common transcription errors and correct them.
  5. Evaluate patient data to support decision-making.
  6. Master professional communication protocols in scribe roles.

Cheat Sheet

  1. Master medical terminology - Decoding complex words turns you into a medical super-sleuth! Break "cardiomyopathy" into "cardio-" (heart), "-myo-" (muscle) and "-pathy" (disease) for precise charting. Regular practice sharpens your documentation skills.
  2. Spot key patient details - Focus on chief complaint, history of present illness (HPI), review of systems (ROS) and physical exam findings like a pro. Gathering these pillars ensures every chart is complete and makes providers cheer.
  3. Master EHR navigation - Dive into electronic charts with confidence. Practice entering data, pulling up histories and updating meds quickly to keep pace in a bustling clinic. Smooth skills equal efficient care.
  4. Catch transcription slip-ups - Hunting typos and mix-ups makes you a safety net. Mix "hyper-" and "hypo-"? Yikes! Proofread like a hawk to prevent costly errors and earn high-fives from your team.
  5. Analyze patient data - Labs, scans and notes are your clues. Practice interpreting numbers and images to support decisions and craft a robust patient story. Critical thinking boosts your scribe superpowers.
  6. Communicate professionally - Confidentiality, clarity and objectivity are your mantra. Stick to facts, ditch personal bias and respect patient privacy for records that shine with integrity.
  7. Master the SOAP note - Subjective, Objective, Assessment and Plan is your roadmap. This framework keeps info organized and teams informed, turning chaos into a clear care path.
  8. Know your abbreviations - "q.d." means once daily and "b.i.d." means twice daily - tiny shortcuts with big impact. Nail these to speed up charting without risking confusion.
  9. Listen actively - Patient stories matter. Lean in, ask smart follow-ups and capture their narrative in full. Empathy plus accuracy equals stellar documentation and happier providers.
  10. Stay legally savvy - HIPAA and ethical rules aren't just fine print - they're your shield. Know patient rights, follow regulations and guard confidentiality to keep charts compliant and trustworthy.
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