MS Medical Scribe Terminology & Documentation 2

Question 1

In SOAP note documentation, where would a scribe record a patient's blood pressure reading obtained during the visit?

Accepted Answer

Objective

Answer

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?

Accepted Answer

BID

Answer

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?

Accepted Answer

Difficulty breathing

Answer

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?

Accepted Answer

As needed

Answer

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?

Accepted Answer

History taking

Answer

History taking captures the patient's past medical history (PMH), surgical history, family history (FH), and social history (SH).

(MS) Medical Scribe Certification Practice Test