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Quizzes > Health & Medicine > Human Anatomy & Medicine

Test Your Medical Scribe Skills with This Practice Quiz!

Ready for the Ultimate Scribe Typing Test? Dive In!

Difficulty: Moderate
2-5mins
Learning OutcomesCheat Sheet
Paper art illustration for medical scribe practice quiz on a sky blue background

This medical scribe practice quiz helps you check exam basics, work through real chart notes, and time your typing. Get instant feedback so you can spot gaps before the certification exam and build speed and accuracy. For more context, try the practice scenarios and a transcription sample as you go.

What is the primary role of a medical scribe in the exam room?
Provide direct patient education
Document the patient encounter accurately
Prescribe medications
Perform physical examinations
Medical scribes are responsible for capturing the clinician-patient interaction in real time, ensuring accurate documentation of history, exam, and plan. They do not perform physical exams, educate patients directly, or prescribe medications. Their role focuses on record-keeping to allow the clinician to focus on patient care.
In a SOAP note, what does the 'S' stand for?
Systematic
Social
Subjective
Situational
The 'S' in SOAP notes stands for Subjective, which captures the patient's report of symptoms and history. The other components are Objective, Assessment, and Plan. This format is widely used to structure clinical documentation.
HIPAA is an important regulation in healthcare. What does HIPAA stand for?
Hospital Identification, Privacy, and Accountability Act
Health Information Portability and Authorization Act
Health Information Protection and Access Act
Health Insurance Portability and Accountability Act
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, which protects patient privacy and secures health information. It sets national standards for the protection of health information. Compliance is essential for all healthcare staff.
In medical shorthand, what does 'BID' mean?
Once a day
As needed
Three times a day
Twice a day
BID stands for 'bis in die' in Latin, meaning twice a day. It is commonly used in prescriptions. Misinterpreting dosage abbreviations can lead to medication errors.
What is the normal adult resting heart rate range?
60 - 100 beats per minute
40 - 60 beats per minute
30 - 50 beats per minute
100 - 120 beats per minute
A normal adult resting heart rate ranges from 60 to 100 beats per minute. Rates below or above this range may indicate bradycardia or tachycardia. Monitoring vital signs accurately is critical in documentation.
In the EMR, where is a patient's allergy information typically documented?
Vital signs log
Medications section
Problem list
Allergies section
Most electronic medical records have a dedicated Allergies section to document patient sensitivities. This ensures quick access during medication ordering. Including allergies prevents adverse drug events.
What is the normal body temperature in Celsius for adults?
37°C
98.6°C
100°F
36.5°C
The average normal body temperature is approximately 37°C. The figure 98.6°F is the equivalent in Fahrenheit. Temperatures significantly above or below can indicate febrile or hypothermic states.
In medical context, what does 'ED' stand for?
Exam Document
Effective Dose
Eating Disorder
Emergency Department
ED commonly refers to the Emergency Department, where acute care is provided. It is a standard abbreviation used in hospital settings. Other expansions would be context-specific and less common.
Which prefix means 'before' in medical terminology?
Retro-
Anti-
Post-
Pre-
The prefix 'pre-' denotes 'before' in medical terms, such as prenatal (before birth). 'Post-' means 'after'. Understanding prefixes aids accurate note-taking.
In prescription shorthand, what does 'HS' mean?
At bedtime
Twice a day
At meal time
Every hour
HS stands for 'hora somni', Latin for 'at bedtime'. It directs when a medication should be taken. Misinterpretation can lead to dosing errors.
Which section of the EMR contains a list of current medications?
Family history section
Plan section
Medications section
Allergies section
The Medications section of an EMR lists all current prescriptions and dosing. Accurate medication lists are vital for safety checks. It is separate from allergies and plan sections.
What does HPI stand for in medical documentation?
Hospital Patient Identification
Health Plan Initiative
Home Physical Inspection
History of Present Illness
HPI stands for History of Present Illness, detailing the patient's symptoms and timeline. It is the central narrative of a clinical encounter. Capturing it accurately is a key scribe responsibility.
Which vital sign measures oxygen saturation?
SpO2
Blood pressure
Respiratory rate
Heart rate
SpO2 is the peripheral capillary oxygen saturation measured by pulse oximetry. It reflects how much oxygen hemoglobin carries. It is distinct from vital signs like blood pressure and heart rate.
Which of the following is NOT considered a standard vital sign?
Blood pressure
Weight
Respiratory rate
Temperature
Weight is not a standard vital sign; the four standard vital signs are temperature, pulse, respiratory rate, and blood pressure. Weight is important but recorded separately. Vital signs indicate immediate physiologic status.
What term describes abnormally rapid breathing?
Hypertension
Bradycardia
Hypoxia
Tachypnea
Tachypnea refers to an increased respiratory rate above the normal range. Bradycardia is slow heart rate, hypertension is high blood pressure, and hypoxia is low oxygen level. Recognizing terms is essential for accurate charting.
In prescription notation, what does 'q4h' indicate?
Every hour
At 4 PM
Every 4 hours
Four times daily
The prefix 'q' stands for 'quaque' in Latin, meaning 'every,' so 'q4h' means every four hours. Accurate interpretation of frequency abbreviations prevents dosing errors.
In a SOAP note, where are laboratory and imaging results documented?
Objective
Assessment
Plan
Subjective
The Objective section of a SOAP note includes measurable, observable data such as vital signs, lab values, and imaging results. Subjective covers patient-reported symptoms. Assessment is the clinician's diagnosis, and Plan outlines management.
The ICD-10 code structure can have up to how many characters?
Seven
Nine
Five
Three
ICD-10 codes can be up to seven alphanumeric characters long, allowing detailed classification. The first three characters define the category, with additional characters for specificity. Accurate coding is essential for billing and quality measures.
Which lab value typically indicates leukocytosis?
Glucose above 200 mg/dL
Hemoglobin below 12 g/dL
White blood cell count above 11,000/µL
Platelets below 150,000/µL
Leukocytosis is defined as an elevated white blood cell count, often above 11,000 per microliter. It can signal infection or inflammation. Accurate lab documentation guides diagnostic assessment.
What is the normal PR interval range on an adult EKG?
120 - 200 milliseconds
240 - 300 milliseconds
200 - 240 milliseconds
80 - 120 milliseconds
The normal PR interval ranges from 120 to 200 ms, reflecting conduction time from atria to ventricles. Values outside this range may indicate heart block or pre-excitation. Scribes must note EKG measurements accurately.
What does the abbreviation 'PRN' indicate in medication orders?
As needed
Before meals
By mouth
Every night
PRN stands for 'pro re nata' in Latin, meaning 'as needed.' It allows patients to take medication based on symptoms rather than at fixed intervals. Proper documentation of PRN orders is critical for safety.
In chart documentation, 'cc' is most often used to indicate:
Coronary care
Cubic centimeter
Chief complaint
Critical care
In medical measurements, 'cc' refers to cubic centimeters, equivalent to milliliters. Although 'CC' can sometimes colloquially denote chief complaint, usage as a volume measure is standard. Clarity prevents dosing mistakes.
Which action should a scribe NEVER perform?
Document patient history
Prescribe or adjust medications
Record physical exam findings
Enter physician orders verbatim
Scribes are unlicensed individuals and should never prescribe or change medication orders. They document information at the direction of the provider. Prescribing constitutes unauthorized practice of medicine.
Which element belongs in the 'Plan' section of a SOAP note?
Diagnostic conclusions
Follow-up instructions
Vital sign measurements
Patient's reported symptoms
The Plan section outlines follow-up steps, treatments, and referrals. Subjective covers symptoms, Objective includes vitals, and Assessment contains diagnostic conclusions. The Plan drives patient care actions.
What does the notation 'NPO' mean?
Normal posture observation
No prescription orders
Nothing by mouth
Night pulse only
NPO stands for 'nil per os' in Latin, meaning nothing by mouth. It is used preoperatively or before certain tests. Correct interpretation ensures patient safety.
A core principle of HIPAA is:
Uploading records to social media
Maintaining patient confidentiality
Allowing open access to all records
Sharing PHI without consent if requested
Maintaining confidentiality of Protected Health Information (PHI) is a key HIPAA principle. It restricts unnecessary disclosure of patient data. Violations can lead to legal and financial penalties.
What is a differential diagnosis?
A patient's family history summary
A list of possible conditions explaining symptoms
A definitive confirmed diagnosis
A set of treatment options
A differential diagnosis is a systematic method clinicians use to identify possible causes of a patient's symptoms before confirming the final diagnosis. It narrows down options through testing and evaluation. Accurate documentation helps guide care.
When encountering unclear dictation, a scribe should:
Make the best guess and proceed
Ask the patient for clarification
Leave it blank and hope it's resolved
Clarify with the provider
Scribes should confirm unclear or inaudible dictations with the provider to ensure accuracy. Guessing can lead to errors in patient records. They should never ask the patient about medical terminology.
Family medical history is documented in which section?
Past medical history
Plan
Objective
Assessment
Family history is part of the Past Medical History (PMH) section. It records hereditary conditions and risks. It is not placed under Assessment or Plan.
What does CPT stand for in medical coding?
Coding Practice Tool
Current Procedural Terminology
Clinical Pathology Test
Certified Procedural Testing
CPT stands for Current Procedural Terminology, the set of codes used to describe medical, surgical, and diagnostic services. It is maintained by the American Medical Association. Accurate CPT coding ensures proper billing.
Charting by exception means:
Use free-text exclusively
Write every detail of the exam
Ignore abnormal findings
Document only deviations from norms
Charting by exception documents only abnormal or significant findings, saving time and focusing on critical data. Normal findings are assumed. This approach requires standardized protocols.
A normal adult respiratory rate is:
8 - 12 breaths per minute
6 - 10 breaths per minute
20 - 30 breaths per minute
12 - 20 breaths per minute
The normal adult respiratory rate ranges from 12 to 20 breaths per minute. Rates outside this range may indicate respiratory distress or abnormal physiology. Accurate charting of vitals is essential.
Which ICD-10 code category corresponds to type 2 diabetes mellitus?
E14
E10
E11
E13
ICD-10 category E11 is designated for type 2 diabetes mellitus, while E10 covers type 1 diabetes. Proper code selection is critical for accurate reporting and billing.
On an EKG, what finding is characteristic of atrial fibrillation?
Prolonged PR interval
Irregularly irregular rhythm without distinct P waves
Delta waves
Sawtooth flutter waves
Atrial fibrillation shows an irregularly irregular ventricular response and no distinct P waves. Sawtooth flutter waves are seen in atrial flutter, delta waves in pre-excitation syndromes, and PR prolongation in first-degree block.
In pharmacology, a drug's half-life is defined as:
Time to reach peak concentration
Time to eliminate all drug from the body
Time required for the drug concentration to decrease by 50%
Duration of therapeutic effect
A drug's half-life is the time it takes for its plasma concentration to reduce by half. It helps determine dosing intervals. Peak concentration and therapeutic duration are related but distinct parameters.
Which lab value is most appropriate to monitor warfarin therapy?
PTT
Platelet count
INR
Bleeding time
The International Normalized Ratio (INR) standardizes prothrombin time for monitoring warfarin anticoagulation. PTT is used for heparin monitoring. Platelet count and bleeding time assess other aspects of hemostasis.
The Beers Criteria is used to:
Determine infectious disease treatment
Identify potentially inappropriate medications in older adults
Grade severity of emergency conditions
Classify psychiatric disorders
The Beers Criteria lists medications that may be inappropriate or higher-risk for patients aged 65 and older. It guides prescribers and helps avoid adverse drug events in the elderly.
What is the normal arterial blood pH range?
7.15 - 7.25
7.45 - 7.55
7.35 - 7.45
7.25 - 7.35
Normal arterial blood pH ranges from 7.35 to 7.45. Deviations indicate acidosis or alkalosis. Accurate lab interpretation is essential in critical care documentation.
Which CPT code category includes evaluation and management services?
Category III
Category IV
Category I
Category II
Category I CPT codes cover evaluation and management services, along with procedures. Category II and III serve other reporting functions. There is no Category IV in CPT.
Which documentation practice best improves diagnostic accuracy?
Maintaining an up-to-date problem list
Using abbreviations liberally
Copying prior notes without review
Documenting only abnormal findings
An accurate, updated problem list helps clinicians track ongoing diagnoses and reduces omissions. Copy-pasting notes can propagate errors. Standardized documentation practices enhance patient safety.
Protected Health Information (PHI) includes which of the following?
Medical record number
Room number at work
Building address
Generic disease name
PHI includes identifiers like medical record numbers that can link data to a specific patient. Generic disease names alone are not PHI. HIPAA defines 18 identifiers considered PHI.
During EHR downtime, a scribe should:
Attempt to access the EHR remotely
Stop documenting entirely
Delay documentation until months later
Use paper downtime forms
When the EHR is unavailable, downtime protocols involve paper forms or offline templates to capture critical data. Delaying documentation can compromise patient safety and care continuity.
Which practice reduces abbreviation-related errors?
Using any common internet-sourced abbreviations
Using institutionally approved abbreviation lists
Omitting abbreviations entirely
Creating new abbreviations as needed
Institutions maintain standardized abbreviation lists to prevent misinterpretation. Creating new or unapproved abbreviations can increase error risk. Avoiding all abbreviations may be impractical in fast-paced settings.
Which root word refers to the kidney?
Cardi/o
Gastr/o
Hepat/o
Nephr/o
The root 'nephr/o' denotes kidney, as in nephrology. 'Cardi/o' refers to heart, 'hepat/o' to liver, and 'gastr/o' to stomach. Knowledge of roots aids accurate note interpreting.
Which interoperability standard uses FHIR to exchange healthcare data?
National Drug Code
Digital Imaging and Communications in Medicine
Health Level Seven V2
Fast Healthcare Interoperability Resources
FHIR stands for Fast Healthcare Interoperability Resources, a standard for exchanging healthcare information electronically. HL7 V2 is older, DICOM is for imaging, and NDC is a drug coding system. FHIR supports web-based APIs.
The HITECH Act of 2009 primarily aimed to:
Abolish HIPAA privacy rules
Promote meaningful use of EHRs with incentive payments
Standardize ICD-9 codes nationally
Mandate paper records for small practices
The Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized adoption and meaningful use of electronic health records. It did not abolish HIPAA or mandate paper records. It encouraged EHR interoperability.
Natural Language Processing (NLP) in EHRs is used to:
Schedule patient appointments
Encrypt patient records
Extract structured data from free-text notes
Monitor room temperature
NLP algorithms process and analyze free-text clinical notes to extract structured concepts like diagnoses and medications. This enhances data usability for research and coding. It is not used for encryption or scheduling.
A swimlane diagram in workflow analysis helps to:
Design building floor plans
Map roles against tasks to identify handoffs
Track patient vital signs trends
Calculate employee salaries
Swimlane diagrams assign tasks to different roles in parallel lanes, highlighting handoffs and responsibilities. They are used in process improvement, not for budgeting or floor design.
The SEP-1 sepsis measure requires documentation of which key test within 3 hours?
Lipid panel
Blood glucose level
Serum lactate level
Red blood cell count
SEP-1 mandates that a serum lactate level be drawn within three hours of sepsis recognition to assess tissue perfusion. It is a core quality metric tracked by CMS. Glucose and lipid panels are not part of SEP-1.
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Study Outcomes

  1. Understand Key Medical Terminology -

    Gain proficiency in essential terms and abbreviations used in medical scribe practice to ensure accurate and consistent documentation.

  2. Apply Documentation Protocols -

    Learn the best practices for charting patient encounters, using standardized formats to maintain clarity and compliance in medical records.

  3. Demonstrate Efficient Scribe Typing Skills -

    Build speed and accuracy in scribe typing tests through targeted exercises, improving your ability to keep pace with live clinical dictation.

  4. Identify Certification Exam Essentials -

    Recognize the core topics and question formats covered in the medical scribe certification exam to focus your study efforts effectively.

  5. Evaluate Clinical Scenarios -

    Analyze real-world case studies and workflow principles to enhance critical thinking and decision-making during the medical scribe exam.

  6. Optimize Your Test Performance -

    Develop strategies to manage time, reduce errors, and build confidence before taking the medical scribe test or medical scribe exam.

Cheat Sheet

  1. Mastering Medical Terminology -

    Build a strong foundation in anatomy and physiology by breaking down complex terms into roots, prefixes, and suffixes - for example, "hypo-" (below) + "glyc-" (sugar) + "-emia" (blood) = hypoglycemia. Use mnemonic devices like "PIPES" (peri-, intra-, post-, epi-, sub-) to recall common prefixes quickly. Regularly quiz yourself with flashcards from reputable sources such as the National Library of Medicine to boost your medical scribe practice confidence.

  2. SOAP Note Structure -

    Internalize the four pillars of clinical documentation: Subjective (patient's complaint), Objective (vitals, lab values), Assessment (diagnosis), and Plan (treatment). For instance, S: "Pt c/o SOB"; O: "RR 22, SpO₂ 95%"; A: "Possible asthma exacerbation"; P: "Administer albuterol inhaler." Practicing SOAP notes under timed conditions will sharpen your skills for the medical scribe certification exam and real-world scenarios.

  3. Abbreviation and Symbol Precision -

    Familiarize yourself with the Joint Commission's "Do Not Use" list to avoid errors - never write "U" for units or "QD" for daily; instead, spell them out fully. Develop a personal cheat sheet of approved abbreviations like "BP" (blood pressure) and "HR" (heart rate) to maintain clarity. Consistent practice during medical scribe test simulations ensures error-free documentation and guards patient safety.

  4. Effective Scribe Typing Test Techniques -

    Boost your WPM to 60 - 80 with at least 98% accuracy by using online drills emphasizing the home row and common medical terms (e.g., "tachycardia," "hypertension"). Time yourself transcribing recorded physician - patient dialogues to mimic real scribe typing test conditions and track your progress. This focused practice is crucial for excelling in any medical scribe exam or certification hurdle.

  5. EHR Navigation and Workflow Optimization -

    Learn shortcuts, macros, and templates in systems like Epic or Cerner to streamline charting and reduce clicks - e.g., ".vitals" auto-populates height, weight, and BP fields. Understand proper sign-off procedures and addendum protocols to maintain audit trails and compliance. Integrating these best practices into your daily routine strengthens your performance on the medical scribe practice quizzes and beyond.

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