SCRIBEAMERICA ED ALL ANSWERS AND QUESTIONS
SET A+
Chief Complaint - ✔✔the main reason for the pt's ED visit
✔✔pain vs tenderness - ✔✔pt's feelings (subjective) vs physician's assessment
(objective)
✔✔distress - ✔✔the doctor's judgement of discomfort
✔✔baseline - ✔✔an individual's normal state of being
✔✔What CAN scribes do? - ✔✔-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? - ✔✔-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? - ✔✔Manages ED pt flow
✔✔What does the ED Nurse do? - ✔✔Records medical Hx, symptoms, monitors pt,
starts IVs, administers medications, and assists with procedures.
✔✔What does the Unit Secretary do? - ✔✔Places physician's orders, answers phone
calls, pages other specialists/doctors, and organizes pt's paperwork.
✔✔What does the scribe do? - ✔✔Document pt's visit on behalf of the physician.
, ✔✔What is the ED flow? - ✔✔Walk in → triage → bed → physician assessment →
labs/rad/meds → results → MDM → diagnosis → consults → disposition
✔✔What are the 5 vital signs? - ✔✔-RR
-BP
-HR
-temp
-O2 sat
✔✔Level of acuity - ✔✔5 (low) to 1 (high)
✔✔What are all the parts of the chart? - ✔✔-HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
✔✔What goes in each SOAP section? - ✔✔S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
✔✔Pt says "high blood pressure," you write... - ✔✔hypertension (HTN)
✔✔Pt says "high cholesterol," you write... - ✔✔hyperlipidemia (HLD)
✔✔Pt says "diabetes," you write... - ✔✔diabetes mellitus (DM)
✔✔Pt says "I take pills for my diabets," you write... - ✔✔non-insulin dependent diabetes
mellitus (NIDDM)
✔✔Pt says "I take shots (insulin) for my diabetes," you write... - ✔✔insulin dependent
diabetes mellitus (IDDM)
✔✔Pt says "heart disease," you write... - ✔✔coronary artery disease (CAD)
✔✔Pt says "heart attack," you write... - ✔✔myocardial infarction (MI) and CAD
✔✔Pt says "heart failure," you write... - ✔✔congestive heart failure (CHF)
✔✔Pt says "irregular heartbeat," you write... - ✔✔atrial fibrillation (a fib) or arrhythmia
SET A+
Chief Complaint - ✔✔the main reason for the pt's ED visit
✔✔pain vs tenderness - ✔✔pt's feelings (subjective) vs physician's assessment
(objective)
✔✔distress - ✔✔the doctor's judgement of discomfort
✔✔baseline - ✔✔an individual's normal state of being
✔✔What CAN scribes do? - ✔✔-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? - ✔✔-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? - ✔✔Manages ED pt flow
✔✔What does the ED Nurse do? - ✔✔Records medical Hx, symptoms, monitors pt,
starts IVs, administers medications, and assists with procedures.
✔✔What does the Unit Secretary do? - ✔✔Places physician's orders, answers phone
calls, pages other specialists/doctors, and organizes pt's paperwork.
✔✔What does the scribe do? - ✔✔Document pt's visit on behalf of the physician.
, ✔✔What is the ED flow? - ✔✔Walk in → triage → bed → physician assessment →
labs/rad/meds → results → MDM → diagnosis → consults → disposition
✔✔What are the 5 vital signs? - ✔✔-RR
-BP
-HR
-temp
-O2 sat
✔✔Level of acuity - ✔✔5 (low) to 1 (high)
✔✔What are all the parts of the chart? - ✔✔-HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
✔✔What goes in each SOAP section? - ✔✔S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
✔✔Pt says "high blood pressure," you write... - ✔✔hypertension (HTN)
✔✔Pt says "high cholesterol," you write... - ✔✔hyperlipidemia (HLD)
✔✔Pt says "diabetes," you write... - ✔✔diabetes mellitus (DM)
✔✔Pt says "I take pills for my diabets," you write... - ✔✔non-insulin dependent diabetes
mellitus (NIDDM)
✔✔Pt says "I take shots (insulin) for my diabetes," you write... - ✔✔insulin dependent
diabetes mellitus (IDDM)
✔✔Pt says "heart disease," you write... - ✔✔coronary artery disease (CAD)
✔✔Pt says "heart attack," you write... - ✔✔myocardial infarction (MI) and CAD
✔✔Pt says "heart failure," you write... - ✔✔congestive heart failure (CHF)
✔✔Pt says "irregular heartbeat," you write... - ✔✔atrial fibrillation (a fib) or arrhythmia
