ScribeAmerica ED Final Exam| 180 QUESTIONS| WITH
COMPLETE SOLUTIONS 2022/2023
Chief Complaint - correct answerthe main reason for the pt's ED visit pain vs tenderness - correct answerpt's feelings (subjective) vs physician's assessment (objective) distress - correct answerthe doctor's judgement of discomfort baseline - correct answeran individual's normal state of being What CAN scribes do? - correct answer-Document Hx, PE, results, procedures, and physician consults -Access and document lab results and radiology findings -Locate and obtains PMHx, previous charts, past results, and recent studies -Record physician interpretations of x-rays and EKGs What can scribes NOT do? - correct answer-Touch pts -Write orders or Rxs -Give verbal orders -Partake in any activity that may affect pt health/outcome -Sign or authenticate any chart/record -Handle bodily fluids or specimens What does the Charge Nurse do? - correct answerManages ED pt flow What does the ED Nurse do? - correct answerRecords medical Hx, symptoms, monitors pt, starts IVs, administers medications, and assists with procedures.What does the Unit Secretary do? - correct answerPlaces physician's orders, answers phone calls, pages other specialists/doctors, and organizes pt's paperwork. 1 / 3
What does the scribe do? - correct answerDocument pt's visit on behalf of the physician.What is the ED flow? - correct answerWalk in → triage → bed → physician assessment → labs/rad/meds → results → MDM → diagnosis → consults → disposition What are the 5 vital signs? - correct answer-RR -BP -HR -temp -O2 sat Level of acuity - correct answer5 (low) to 1 (high) What are all the parts of the chart? - correct answer-HPI -ROS -Past Hx -PE -ED Course -Disposition
What goes in each SOAP section? - correct answerS: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... - correct answerhypertension (HTN) Pt says "high cholesterol," you write... - correct answerhyperlipidemia (HLD) 2 / 3
Pt says "diabetes," you write... - correct answerdiabetes mellitus (DM) Pt says "I take pills for my diabets," you write... - correct answernon-insulin dependent diabetes mellitus
(NIDDM)
Pt says "I take shots (insulin) for my diabetes," you write... - correct answerinsulin dependent diabetes mellitus (IDDM) Pt says "heart disease," you write... - correct answercoronary artery disease (CAD) Pt says "heart attack," you write... - correct answermyocardial infarction (MI) and CAD Pt says "heart failure," you write... - correct answercongestive heart failure (CHF) Pt says "irregular heartbeat," you write... - correct answeratrial fibrillation (a fib) or arrhythmia Pt says "murmur," you write... - correct answerheart murmur Pt says "abnormally fast/racing heartbeat," you write... - correct answersupraventricular tachycardia (SVT) or arrhythmia Pt says "emphysema/chronic bronchitis," you write... - correct answerchronic obstructive pulmonary disease (COPD) Pt says "blood clot in lung," you write... - correct answerpulmonary embolism (PE) Pt says "pneumonia," you write... - correct answerpneumonia (PNA) Pt says "reflux," you write... - correct answergastroesophageal reflux disease (GERD)
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