Medical Scribe Quiz 1 Latest Update Graded A+

Medical Scribe Quiz 1 Latest Update Graded A+ Chief Complaint Primary reason for visit Palpation Act of pressing on an area Inpatient Admitted to hospital Outpatient Care outside of the hospital such as primary care, hospice What does a scribe do? Document patient history, physical exam, results, procedures Access documents such as lab tests, radiology, past medical history, charts Record physician assessment Charge Nurse Manages ED patient flow Mid Level Provider Licensed Nurse Practitioner or PA that works under doctor to diagnose and treat patients ED Nurse Records histories, symptoms, monitors patient, starts IVs, administers medications and assists with procedures Respiratory Therapist Administers "breathing treatments", manages pt airway ED Tch Helps nurse with procedures Unit Secretary Places orders, answers phone calls, paperwork Triage Assess patient, take vital signs, determine level of acuity Vital signs Heart Rate Blood Pressure Respiratory Rate Temperature Oxygen Saturation Subjective History of Present Illness (HPI) Review of Systems (ROS) History (Hx) Medical, Surgical, Family, Social Histories Objective Physical Examination Differential Diagnosis (Dx) List of possible diagnoses that further tests require to arrive at Final Diagnoses ED Course Objective results that arrive from labs, imaging, evaluations, etc. What happened when patient was in ER Patient has high cholestrol Past History Patient was given an antiemetic in the ED ED Course EKG shows Normal Sinus Rhythm ED Course Patient came to the ED for chest pain HPI Patient stubbed toe last week ROS Complete Blood Count shows anemia EDC Patient is in no acute distress Physical Examination Distress indicates "objective" physician's assessment Patient feels better after antiemetic EDC