MS Medical Scribe Terminology & Documentation 2 — Questions and Answers
Question 1: In SOAP note documentation, where would a scribe record a patient's blood pressure reading obtained during the visit?
- Subjective
- Objective (Correct answer)
- Assessment
- Plan
Correct answer: Objective
Vital signs and physical examination findings are measurable data recorded in the Objective section of a SOAP note.
Question 2: Which abbreviation correctly documents that a medication should be taken twice daily?
- QD
- BID (Correct answer)
- TID
- QID
Correct answer: BID
BID (bis in die) is the Latin abbreviation meaning twice daily, while QD=once daily, TID=three times daily, QID=four times daily.
Question 3: A physician documents 'the patient denies dyspnea.' What does dyspnea mean?
- Chest pain
- Difficulty breathing (Correct answer)
- Difficulty swallowing
- Painful urination
Correct answer: Difficulty breathing
Dyspnea refers to shortness of breath or difficulty breathing, derived from the Greek 'dys' (difficult) and 'pnoia' (breathing).
Question 4: What does the medical abbreviation 'PRN' indicate on a medication order?
- Before meals
- As needed (Correct answer)
- At bedtime
- Immediately
Correct answer: As needed
PRN (pro re nata) is a Latin phrase meaning 'as needed,' indicating medication should be taken only when required.
Question 5: Which term describes the process of recording a patient's past medical history, surgeries, and family health conditions?
- Chief complaint documentation
- History taking (Correct answer)
- Physical examination
- Differential diagnosis
Correct answer: History taking
History taking captures the patient's past medical history (PMH), surgical history, family history (FH), and social history (SH).
Question 6: A scribe hears 'the patient has tachycardia.' What heart rate would be consistent with this diagnosis in an adult?
- 55 beats per minute
- 72 beats per minute
- 110 beats per minute (Correct answer)
- 45 beats per minute
Correct answer: 110 beats per minute
Tachycardia is defined as a heart rate greater than 100 beats per minute in adults.
Question 7: In medical documentation, what does the abbreviation 'HPI' stand for?
- Health Prevention Index
- History of Present Illness (Correct answer)
- Hospital Patient Information
- High Priority Intervention
Correct answer: History of Present Illness
HPI stands for History of Present Illness, which describes the development and context of the patient's current complaint.
MS Medical Scribe Terminology & Documentation 2
In SOAP note documentation, where would a scribe record a patient's blood pressure reading obtained during the visit?