Scribeamerica Ed Final Exam With Complete Solutions

SCRIBEAMERICA ED FINAL EXAM
WITH COMPLETE SOLUTIONS




ChiefvComplaintv-vcorrectvanswer-thevmainvreasonvforvthevpt'svEDvvisit

painvvsvtendernessv-vcorrectvanswer-
pt'svfeelingsv(subjective)vvsvphysician'svassessmentv(objective)

distressv-vcorrectvanswer-thevdoctor'svjudgementvofvdiscomfort

baselinev-vcorrectvanswer-anvindividual'svnormalvstatevofvbeing

WhatvCANvscribesvdo?v-vcorrectvanswer--
DocumentvHx,vPE,vresults,vprocedures,vandvphysicianvconsults
-Accessvandvdocumentvlabvresultsvandvradiologyvfindings
-LocatevandvobtainsvPMHx,vpreviousvcharts,vpastvresults,vandvrecentvstudies
-Recordvphysicianvinterpretationsvofvx-raysvandvEKGs

WhatvcanvscribesvNOTvdo?v-vcorrectvanswer--Touchvpts
-WritevordersvorvRxs
-Givevverbalvorders
-Partakevinvanyvactivityvthatvmayvaffectvptvhealth/outcome
-Signvorvauthenticatevanyvchart/record
-Handlevbodilyvfluidsvorvspecimens

WhatvdoesvthevChargevNursevdo?v-vcorrectvanswer-ManagesvEDvptvflow

WhatvdoesvthevEDvNursevdo?v-vcorrectvanswer-
RecordsvmedicalvHx,vsymptoms,vmonitorsvpt,vstartsvIVs,vadministersvmedications,vandv
assistsvwithvprocedures.

WhatvdoesvthevUnitvSecretaryvdo?v-vcorrectvanswer-
Placesvphysician'svorders,vanswersvphonevcalls,vpagesvothervspecialists/
doctors,vandvorganizesvpt'svpaperwork.

Whatvdoesvthevscribevdo?v-vcorrectvanswer-
Documentvpt'svvisitvonvbehalfvofvthevphysician.

, WhatvisvthevEDvflow?v-vcorrectvanswer-
Walkvinv→vtriagev→vbedv→vphysicianvassessmentv→vlabs/rad/
medsv→vresultsv→vMDMv→vdiagnosisv→vconsultsv→vdisposition

Whatvarevthev5vvitalvsigns?v-vcorrectvanswer--RR
-BP
-HR
-temp
-O2vsat

Levelvofvacuityv-vcorrectvanswer-5v(low)vtov1v(high)

Whatvarevallvthevpartsvofvthevchart?v-vcorrectvanswer--HPI
-ROS
-PastvHx
-PE
-EDvCourse
-Disposition

WhatvgoesvinveachvSOAPvsection?v-vcorrectvanswer-S:vHPIvandvROS
O:vPEvandvEDvcourse
A:vdiagnosis
P:vplanvandvdisposition

Ptvsaysv"highvbloodvpressure,"vyouvwrite...v-vcorrectvanswer-hypertensionv(HTN)

Ptvsaysv"highvcholesterol,"vyouvwrite...v-vcorrectvanswer-hyperlipidemiav(HLD)

Ptvsaysv"diabetes,"vyouvwrite...v-vcorrectvanswer-diabetesvmellitusv(DM)

Ptvsaysv"Ivtakevpillsvforvmyvdiabets,"vyouvwrite...v-vcorrectvanswer-non-
insulinvdependentvdiabetesvmellitusv(NIDDM)

Ptvsaysv"Ivtakevshotsv(insulin)vforvmyvdiabetes,"vyouvwrite...v-vcorrectvanswer-
insulinvdependentvdiabetesvmellitusv(IDDM)

Ptvsaysv"heartvdisease,"vyouvwrite...v-vcorrectvanswer-coronaryvarteryvdiseasev(CAD)

Ptvsaysv"heartvattack,"vyouvwrite...v-vcorrectvanswer-myocardialvinfarctionv(MI)vandvCAD

Ptvsaysv"heartvfailure,"vyouvwrite...v-vcorrectvanswer-congestivevheartvfailurev(CHF)

Ptvsaysv"irregularvheartbeat,"vyouvwrite...v-vcorrectvanswer-
atrialvfibrillationv(avfib)vorvarrhythmia

Ptvsaysv"murmur,"vyouvwrite...v-vcorrectvanswer-heartvmurmur

Ptvsaysv"abnormallyvfast/racingvheartbeat,"vyouvwrite...v-vcorrectvanswer-
supraventricularvtachycardiav(SVT)vorvarrhythmia