Scribe America Final Exam Review Questions with Complete Solutions

Scribe America Final Exam Review Questions with Complete Solutions 1 / 13 1. Fill in the blanks for ED flow: Walk-in -- -- Bed -- Physician Assessment -- Lab/Rad/Meds -- Results -- MDM -- Diagnosis -- Consults -- : 1. Triage 2. Disposition (Discharge (DC), Admit, Transfer) 2. What are the 5 vital signs?: HR, BP, Respiratory rate, Temperature, Oxygen Saturation 3. The HPI and ROS are what type of information?: subjective 4. While evaluating a patient c/o CP, your physician tells you that "the heart sounds are normal". Where would you document this?: PE 5. Would you be contradicting yourself if you wrote "The patient has abdominal pain" in the HPI, but then later in the PE documented "The abdomen is non-tender". Why or why not?: No, a patient complaining of abdominal pain is a subjective complaint while a non-tender abdomen is an objective finding (by thephysician) 6. What is the difference bt the HPI and ROS?: HPI focuses on the details related to the chief complain. ROS is a head-to-toe checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have. 7. What does disposition (dispo) mean?: The patient's destination after they leave the Emergency Department 8. What subcategories are included within the Past History section of the template?: PMHx: Past medical history (HTN, DM, HLD, CAD, MI...) PSHx: Past surgical history (appendectomy, Cholecystectomy, CABG...) FHx: Family History (Hx of CAD 55 y/o) SHx: Social History (ETOH, Smoking, Drug Abuse, Occupation...) 9. Abbreviation for a heart attack: myocardial infarction (MI) 10. Abbreviation for high blood pressure: Hypertension (HTN) 11. What is the medical term for acid reflux?: GERD (gastroesophageal reflux disease) 12. Medical term for stroke?: Cerebrovascular Accident (CVA) 13. Term for gallbladder removal?: Cholesystectomy 14. What does NKDA stand for?: No known drug allergies 15. Medical term for redness: erythema