Scribe America ED Final Exam with 100% Correct Answers 2023 Chief Complaint - Correct Answer the main reason for the pt's ED visit pain vs tenderness - Correct Answer pt's feelings (subjective) vs physician's assessment (objective) distress - Correct Answer the doctor's judgement of discomfort baseline - Correct Answer an 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 Answer Manages ED pt flow What does the ED Nurse do? - Correct Answer Records medical Hx, symptoms, monitors pt, starts IVs, administers medications, and assists with procedures.What does the Unit Secretary do? - Correct Answer Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes pt's paperwork.What does the scribe do? - Correct Answer Document pt's visit on behalf of the physician.What is the ED flow? - Correct Answer Walk 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 Answer 5 (low) to 1 (high) 1 / 2
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 Answer S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... - Correct Answer hypertension (HTN) Pt says "high cholesterol," you write... - Correct Answer hyperlipidemia (HLD) Pt says "diabetes," you write... - Correct Answer diabetes mellitus (DM) Pt says "I take pills for my diabets," you write... - Correct Answer non-insulin dependent diabetes mellitus (NIDDM) Pt says "I take shots (insulin) for my diabetes," you write... - Correct Answer insulin dependent diabetes mellitus (IDDM) Pt says "heart disease," you write... - Correct Answer coronary artery disease (CAD) Pt says "heart attack," you write... - Correct Answer myocardial infarction (MI) and CAD Pt says "heart failure," you write... - Correct Answer congestive heart failure (CHF) Pt says "irregular heartbeat," you write... - Correct Answer atrial fibrillation (a fib) or arrhythmia Pt says "murmur," you write... - Correct Answer heart murmur Pt says "abnormally fast/racing heartbeat," you write... - Correct Answer supraventricular tachycardia (SVT) or arrhythmia Pt says "emphysema/chronic bronchitis," you write... - Correct Answer chronic obstructive pulmonary disease (COPD) Pt says "blood clot in lung," you write... - Correct Answer pulmonary embolism (PE) Pt says "pneumonia," you write... - Correct Answer pneumonia (PNA)
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