ScribeAmerica ED [2026/2027] | UPDATED
ACTUAL Exam Question and Answer | Ultimate
Exam Prep
• 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
• Pt says "murmur," you write... -✓✓ heart murmur
• Pt says "abnormally fast/racing heartbeat," you write... -✓✓ supraventricular
tachycardia (SVT) or arrhythmia
• Pt says "emphysema/chronic bronchitis," you write... -✓✓ chronic obstructive
pulmonary disease (COPD)
• Pt says "blood clot in lung," you write... -✓✓ pulmonary embolism (PE)
• Pt says "pneumonia," you write... -✓✓ pneumonia (PNA)
• Pt says "reflux," you write... -✓✓ gastroesophageal reflux disease (GERD)
• Pt says "ulcer," you write... -✓✓ gastric ulcer or peptic ulcer disease (PUD)
• Pt says "kidney stones," you write... -✓✓ renal calculi
ACTUAL Exam Question and Answer | Ultimate
Exam Prep
• 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
• Pt says "murmur," you write... -✓✓ heart murmur
• Pt says "abnormally fast/racing heartbeat," you write... -✓✓ supraventricular
tachycardia (SVT) or arrhythmia
• Pt says "emphysema/chronic bronchitis," you write... -✓✓ chronic obstructive
pulmonary disease (COPD)
• Pt says "blood clot in lung," you write... -✓✓ pulmonary embolism (PE)
• Pt says "pneumonia," you write... -✓✓ pneumonia (PNA)
• Pt says "reflux," you write... -✓✓ gastroesophageal reflux disease (GERD)
• Pt says "ulcer," you write... -✓✓ gastric ulcer or peptic ulcer disease (PUD)
• Pt says "kidney stones," you write... -✓✓ renal calculi
