Scribe America ED Final Exam

Chief Complaint - Correct answer-the main reason for the pt's ED visit pain vs tenderness - Correct answer-pt's feelings (subjective) vs physician's assessment (objective) distress - Correct answer-the doctor's judgement of discomfort baseline - Correct answer-an individual's normal state of being What CAN scribes do? - Correct 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? - Correct 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? - Correct answer-Manages ED pt flow What does the ED Nurse do? - Correct answer-Records medical Hx, symptoms, monitors pt, starts IVs, administers medications, and assists with procedures. What does the Unit Secretary do? - Correct answer-Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes pt's paperwork. What does the scribe do? - Correct answer-Document pt's visit on behalf of the physician. What is the ED flow? - Correct answer-Walk in → triage → bed → physician assessment → labs/rad/meds → results → MDM → diagnosis → consults → disposition What are the 5 vital signs? - Correct answer--RR -BP -HR -temp -O2 sat Level of acuity - Correct answer-5 (low) to 1 (high) Pt says "high blood pressure," you write... - Correct answer-hypertension (HTN) Pt says "high cholesterol," you write... - Correct answer-hyperlipidemia (HLD) Pt says "diabetes," you write... - Correct answer-diabetes mellitus (DM) Pt says "I take pills for my diabets," you write... - Correct answer-non-insulin dependent diabetes mellitus (NIDDM) Pt says "I take shots (insulin) for my diabetes," you write... - Correct answer-insulin dependent diabetes mellitus (IDDM) Pt says "heart disease," you write... - Correct answer-coronary artery disease (CAD) Pt says "heart attack," you write... - Correct answer-myocardial infarction (MI) and CAD Pt says "heart failure," you write... - Correct answer-congestive heart failure (CHF) Pt says "irregular heartbeat," you write... - Correct answer-atrial fibrillation (a fib) or arrhythmia Pt says "murmur," you write... - Correct answer-heart murmur Pt says "abnormally fast/racing heartbeat," you write... - Correct answersupraventricular tachycardia (SVT) or arrhythmia Pt says "emphysema/chronic bronchitis," you write... - Correct answer-chronic obstructive pulmonary disease (COPD) Pt says "blood clot in lung," you write... - Correct answer-pulmonary embolism (PE) Pt says "pneumonia," you write... - Correct answer-pneumonia (PNA) What are all the parts of the chart? - Correct answer--HPI -ROS -Past Hx -PE -ED Course -Disposition What goes in each SOAP section? - Correct answer-S: HPI and ROS O: PE and ED course