Scribe America ED Final Exam Q&As (Latest Update), Exams of Science
education
Chief Complaint - ANSWERthe main reason for the pt's ED visit
pain vs tenderness - ANSWERpt's feelings (subjective) vs physician's
assessment (objective)
distress - ANSWERthe doctor's judgement of discomfort
baseline - ANSWERan 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? - ANSWERManages ED pt flow
What does the ED Nurse do? - ANSWERRecords medical Hx, symptoms,
monitors pt, starts IVs, administers medications, and assists with procedures.
What does the Unit Secretary do? - ANSWERPlaces physician's orders,
ANSWERs phone calls, pages other specialists/doctors, and organizes pt's
paperwork.
What does the scribe do? - ANSWERDocument pt's visit on behalf of the
physician.
What is the ED flow? - ANSWERWalk 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 - ANSWER5 (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? - ANSWERS: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... - ANSWERhypertension (HTN)
Pt says "high cholesterol," you write... - ANSWERhyperlipidemia (HLD)
Pt says "diabetes," you write... - ANSWERdiabetes mellitus (DM)
Pt says "I take pills for my diabets," you write... - ANSWERnon-insulin
dependent diabetes mellitus (NIDDM)
education
Chief Complaint - ANSWERthe main reason for the pt's ED visit
pain vs tenderness - ANSWERpt's feelings (subjective) vs physician's
assessment (objective)
distress - ANSWERthe doctor's judgement of discomfort
baseline - ANSWERan 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? - ANSWERManages ED pt flow
What does the ED Nurse do? - ANSWERRecords medical Hx, symptoms,
monitors pt, starts IVs, administers medications, and assists with procedures.
What does the Unit Secretary do? - ANSWERPlaces physician's orders,
ANSWERs phone calls, pages other specialists/doctors, and organizes pt's
paperwork.
What does the scribe do? - ANSWERDocument pt's visit on behalf of the
physician.
What is the ED flow? - ANSWERWalk 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 - ANSWER5 (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? - ANSWERS: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... - ANSWERhypertension (HTN)
Pt says "high cholesterol," you write... - ANSWERhyperlipidemia (HLD)
Pt says "diabetes," you write... - ANSWERdiabetes mellitus (DM)
Pt says "I take pills for my diabets," you write... - ANSWERnon-insulin
dependent diabetes mellitus (NIDDM)
