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ScribeAmerica ED Final Exam Study Guide 1.Subjective vs. Objective
: Feeling vs. Fact
2.Chief Complaint (CC)
: The main reason for the patient's ED visit
3.Medical Decision Making (MDM)
: The physician's thought process
4.Pain vs. Tenderness
: patient's feeling vs. physician's assessment (subjective)
5.Benign 1 / 4
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: Normal, nothing of concern
6.Distress
: The doctor's judgement of discomfort (objective)
7.Febrile
: The state of having a fever, concerning for infection
8.Acute
: New onset, likely concerning
9.Chronic
: Long-standing, not of direct concern (90 days- 3mo)
10.Baseline
: An individual's normal state of being 2 / 4
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11.Auscultatio
: Listening with a stethoscope
12.Palpation
: The act of pressing on an area (by the doctor)
13.Inpatient
: Admitted to the hospital overnight
14.Outpatient
: Seen and sent home the same day
15.Scribes CAN
: 1. Document the history, physical exam, results, procedures, and
physician consults 2.Access and document laboratory results and radiology findings 3.Access and display X-Rays for the physician to review 3 / 4
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4.Locate and obtain PMHx, previous charts, past results, and recent studies 5.Record physician interpretations of X-Rays and ECG's 16.Scribes CANNOT
: 1. Touch patients
2.Write orders or prescriptions 3.Give verbal orders 4.Partake in any activity that may affect patient health or outcome 5.Sign or authenticate any chart or record 6.Handle bodily fluids or specimens 7.
17.People in the Emergency Department : 1. Charge Nurse: manages the ED patient flow.
2.Mid-level provider: Nurse Practitioner (NP) or Physician Assistant (PA)
that works under the supervision of a physician to diagnose and treat patients
3.ED Nurse: Records medical histories, symptoms, monitors the
patient, starts IVs, administers medications, and assists with procedures
4.Respiratory Therapist (RT) : Administers "breathing treatments" and
assists with managing a patient's airway
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