Practice Test Geeks(MS) Medical Scribe Certification Practice Test
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Patient Assessment & Documentation Flashcards

7 cards from real MS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.

Read the first 7 Patient Assessment & Documentation flashcards as text

  1. When a scribe documents 'Pt c/o N/V x2 days,' what is the patient experiencing?

    Answer: Nausea and vomiting for 2 days

    N/V is the abbreviation for nausea and vomiting, and 'x2 days' indicates the symptom duration.

  2. Which section of the physical exam documents findings such as heart rate, blood pressure, temperature, and respiratory rate?

    Answer: Vital Signs

    Vital signs are the measured physiologic parameters including HR, BP, temperature, RR, and oxygen saturation.

  3. A patient's chart notes 'FH: Father with MI at age 55.' What does this mean for documentation purposes?

    Answer: The patient's father had a heart attack at 55

    FH stands for Family History, and MI is myocardial infarction (heart attack); this documents the father's cardiac event.

  4. What does 'PRN' mean in medication documentation?

    Answer: As needed

    PRN is a Latin abbreviation for 'pro re nata,' meaning as needed or as the situation demands.

  5. A physician performs an abdominal exam and documents 'soft, NT, ND, NABS.' What does 'NT' indicate?

    Answer: Non-tender

    NT in abdominal exam documentation stands for non-tender, indicating the patient did not experience pain on palpation.

  6. In medical documentation, 'Hx' is the standard abbreviation for:

    Answer: History

    'Hx' is universally used in medical records as an abbreviation for history.

  7. When documenting a psychiatric patient's mental status exam, the scribe notes 'thought process: linear and goal-directed.' This means the patient:

    Answer: Is thinking logically and coherently

    Linear and goal-directed thought process means the patient's thinking is organized, logical, and stays on topic.

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