ED Scribe - FINAL EXAM Questions & Answers Correctly Answered.

Medical Decision Making (MDM) - Answer-The physician's thought process Pain vs. Tenderness - Answer-Patient's feeling vs. physician's assessment What does distress mean? - Answer-The doctor's judgment of discomfort Baseline - Answer-An individual's normal state of being What does Auscultation mean? - Answer-Listening with a stethoscope Palpation - Answer-The act of pressing on an area by the doctor Inpatient - Answer-Admitted to the hospital overnight Outpatient - Answer-Seen and sent home the same day What is the ED flow (overview)? - Answer-1. Check in and Chief Complaint 2. Physician assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition What is the ED flow before orders are made? - Answer-1. Arrival 2. Triage 3. Vital Signs / Bed Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE What is the ED flow after orders are made? - Answer-1. Differential Dx 2. Physician orders labs, imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition What is the general documentation template? - Answer-HPI ROS PHx PE ED course Disposition Thyroid problem means.. - Answer-Usually Hypothyroidism, sometimes hyperthyroidism"I only take pills for my diabetes" means.. - Answer-Non-Insulin Dependent Diabetes Mellitus - NIDDM "I take shots (insulin) for my diabetes" means.. - Answer-Insulin Dependent Diabetes Mellitus - IDDM Heart disease means.. - Answer-Usually Coronary Artery Disease - CAD