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.

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  1. A scribe documents 'Pt is a 45 y/o M presenting with chest pain.' What does 'y/o' mean?

    Answer: Years old

    In medical documentation, 'y/o' is the standard abbreviation for 'years old,' describing the patient's age.

  2. Which of the following best describes 'radiating pain' in the context of an HPI?

    Answer: Pain that spreads from one location to another

    Radiating pain refers to pain that originates in one area and travels or spreads to another location.

  3. A scribe must document a medication with 'QID' dosing instructions. How many times per day should the medication be taken?

    Answer: Four times

    QID is the abbreviation for 'quater in die,' meaning four times per day.

  4. The physician documents 'GCS: 15' in the neuro exam. What does a GCS score of 15 indicate?

    Answer: Full normal neurological function

    A Glasgow Coma Scale score of 15 is the maximum score, indicating the patient is fully awake and alert with no neurological impairment.

  5. When a provider asks about 'associated symptoms' during the HPI, they are asking about:

    Answer: Other symptoms occurring alongside the primary complaint

    Associated symptoms are additional symptoms the patient experiences in conjunction with the chief complaint.

  6. A patient's chart reads 'Impression: r/o PE.' What does 'r/o' mean?

    Answer: Rule out

    In medical documentation, 'r/o' means 'rule out,' indicating the physician is considering but not confirming a diagnosis.

  7. Which of the following is the correct way to document a blood pressure reading of 120 over 80?

    Answer: BP: 120/80 mmHg

    Blood pressure is documented with systolic over diastolic using a forward slash: 120/80 mmHg.

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