SCRIBEAMERICA FINAL EXAM ED 2026
QUESTIONS WITH ANSWERS GRADED A+
◉ pain vs tenderness. Answer: pt's feelings (subjective) vs physician's
assessment (objective)
◉ distress. Answer: the doctor's judgement of discomfort
◉ baseline. Answer: an individual's normal state of being
◉ What CAN scribes do? 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? 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? Answer: Manages ED pt flow
◉ What does the ED Nurse do? Answer: Records medical Hx,
symptoms, monitors pt, starts IVs, administers medications, and assists
with procedures.
◉ What does the Unit Secretary do? Answer: Places physician's orders,
answers phone calls, pages other specialists/doctors, and organizes pt's
paperwork.
◉ What does the scribe do? Answer: Document pt's visit on behalf of the
physician.
◉ What is the ED flow? Answer: Walk in → triage → bed → physician
assessment → labs/rad/meds → results → MDM → diagnosis →
consults → disposition
◉ What are the 5 vital signs? Answer: -RR
-BP
-HR
-temp
, -O2 sat
◉ Level of acuity. Answer: 5 (low) to 1 (high)
◉ What are all the parts of the chart? Answer: -HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
◉ What goes in each SOAP section? Answer: S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
◉ Pt says "high blood pressure," you write:: Answer: hypertension
(HTN)
◉ Pt says "high cholesterol," you write:: Answer: hyperlipidemia (HLD)
◉ Pt says "diabetes," you write:: Answer: diabetes mellitus (DM)
QUESTIONS WITH ANSWERS GRADED A+
◉ pain vs tenderness. Answer: pt's feelings (subjective) vs physician's
assessment (objective)
◉ distress. Answer: the doctor's judgement of discomfort
◉ baseline. Answer: an individual's normal state of being
◉ What CAN scribes do? 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? 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? Answer: Manages ED pt flow
◉ What does the ED Nurse do? Answer: Records medical Hx,
symptoms, monitors pt, starts IVs, administers medications, and assists
with procedures.
◉ What does the Unit Secretary do? Answer: Places physician's orders,
answers phone calls, pages other specialists/doctors, and organizes pt's
paperwork.
◉ What does the scribe do? Answer: Document pt's visit on behalf of the
physician.
◉ What is the ED flow? Answer: Walk in → triage → bed → physician
assessment → labs/rad/meds → results → MDM → diagnosis →
consults → disposition
◉ What are the 5 vital signs? Answer: -RR
-BP
-HR
-temp
, -O2 sat
◉ Level of acuity. Answer: 5 (low) to 1 (high)
◉ What are all the parts of the chart? Answer: -HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
◉ What goes in each SOAP section? Answer: S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
◉ Pt says "high blood pressure," you write:: Answer: hypertension
(HTN)
◉ Pt says "high cholesterol," you write:: Answer: hyperlipidemia (HLD)
◉ Pt says "diabetes," you write:: Answer: diabetes mellitus (DM)
