Final Exam ED Scribe America with perfect answers 2024

What are the necessary elements to include in the HPI, ROS, PMH/FH/SH, and PE to qualify for level 5 billing? correct answersHPI: 4 elements ROS: 10 systems PMH/FH/SH: 2 of 3 PE: 8 systems (excluding head and neck) what is medical decision making? correct answersthe physician's thought process (MDM) benign (def) correct answersnothing of concern febrile (def) correct answersthe state of having a fever, concerning for infection acute (def) correct answersnew onset, likely concerning distress (def) correct answersthe doctor's judgement of discomfort H&P correct answershistory and physical What are the steps of ED flow (in detail)? correct answersEnter--triage--bed placement--nurse assessment--H&P (HPI, past history, PE)--Dif Dx--physician orders (labs, imaging, procedures, meds)-- results & ED course (re-evaluations, consult specialists)--Final Dx (MDM, r/o DDx, reach final Dx)--disposition What is the general documentation order? correct answersHPI, ROS, Past History, PE, ED course, Disposition What does the ED course consist of? correct answerslabs, imaging, procedures, consultations, medications, events, and re-evaluations (objective results) What are the 5 vital signs? correct answersHR, BP (between 90/60-120/80), RR (Respiratory Rate), temp, Sa02 (96%) What temp is considered febrile in the ED? correct answers 100.4 HTN correct answersHypertension (high bp) HLD correct answershyperlipidemia (high cholesterol) heart disease=? correct answerscoronary artery disease (CAD) heart attack=? correct answersmyocardial infarction (MI)