Scribe America ED Final Exam (All Correct)

Subjective vs. Objective correct answers Feeling vs. Fact Chief Complaint (CC) correct answers The main reason for the patient's ED visit Medical Decision Making (MDM) correct answers The physician's thought process Pain vs. Tenderness correct answers patient's feeling vs. physician's assessment (subjective) Benign correct answers Normal, nothing of concern Distress correct answers The doctor's judgement of discomfort (objective) Febrile correct answers The state of having a fever, concerning for infection Acute correct answers New onset, likely concerning Chronic correct answers Long-standing, not of direct concern (90 days- 3mo) Baseline correct answers An individual's normal state of being Auscultation correct answers Listening with a stethoscope Palpation correct answers The act of pressing on an area (by the doctor) Inpatient correct answers Admitted to the hospital overnight Outpatient correct answers Seen and sent home the same day Scribes CAN correct answers 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 4. Locate and obtain PMHx, previous charts, past results, and recent studies 5. Record physician interpretations of X-Rays and ECG's Scribes CANNOT correct answers 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 People in the Emergency Department correct answers 1. Charge Nurse: manages the ED patient flow.