MS Medical Scribe Clinical Procedures & Workflow 2 — Questions and Answers
Question 1: When a physician performs a laceration repair, which detail is MOST critical for the scribe to document regarding the suture material?
- The brand name of the suture manufacturer
- The type, size, and absorbability of the suture used (Correct answer)
- The color of the suture thread
- The expiration date of the suture package
Correct answer: The type, size, and absorbability of the suture used
Documenting suture type (e.g., nylon, vicryl), size (e.g., 3-0), and whether it is absorbable or non-absorbable is essential for continuity of care and removal planning.
Question 2: A patient arrives with chest pain. The physician orders a 12-lead ECG STAT. As a scribe, what is your immediate role?
- Perform the ECG on the patient
- Document the time the order was placed and when the ECG was completed (Correct answer)
- Interpret the ECG findings for the chart
- Contact the cardiology department directly
Correct answer: Document the time the order was placed and when the ECG was completed
Scribes document the time of orders and completion of procedures to establish a clinical timeline but do not perform or interpret diagnostic tests.
Question 3: During a procedure note for an incision and drainage (I&D), which element describes what was found inside the wound?
- Indication
- Procedure description
- Findings (Correct answer)
- Disposition
Correct answer: Findings
The 'Findings' section of a procedure note details what was observed during the procedure, such as the amount and character of purulent material drained.
Question 4: A physician documents a 'time-out' before a bedside procedure. What does this safety protocol involve?
- A short break for the physician before starting
- Verification of correct patient, procedure, and site before beginning (Correct answer)
- Pausing to obtain verbal consent from the patient mid-procedure
- Checking the patient's insurance before proceeding
Correct answer: Verification of correct patient, procedure, and site before beginning
A surgical time-out is a standardized safety pause to confirm patient identity, correct procedure, and correct site/side before any invasive procedure.
Question 5: When documenting IV access placement, which information is required in the note?
- Only the gauge of the catheter
- Site, gauge, number of attempts, and any complications (Correct answer)
- The nurse's name who placed the IV
- The brand of IV catheter used
Correct answer: Site, gauge, number of attempts, and any complications
IV access documentation should include insertion site (e.g., left antecubital), catheter gauge, number of attempts, and whether any complications such as infiltration occurred.
Question 6: A physician dictates 'the patient tolerated the procedure well.' In what section of the procedure note does this statement typically appear?
- Indications
- Consent
- Post-procedure condition / Disposition (Correct answer)
- Anesthesia
Correct answer: Post-procedure condition / Disposition
Statements about the patient's condition after the procedure and their disposition are recorded in the post-procedure or disposition section of the note.
Question 7: During a lumbar puncture, the physician asks the scribe to record the opening pressure. Where does this value belong in the documentation?
- Chief complaint
- Past medical history
- Procedure findings (Correct answer)
- Review of systems
Correct answer: Procedure findings
Opening pressure measured during lumbar puncture is an intraoperative finding and is documented in the procedure findings or results section.
MS Medical Scribe Clinical Procedures & Workflow 2
When a physician performs a laceration repair, which detail is MOST critical for the scribe to document regarding the suture material?