ScribeAmerica ED Final Exam Questions with Correct Answers.

ScribeAmerica ED Final Exam Questions with
Correct Answers.
Chief Complaint - ANS the main reason for the pt's ED visit

pain vs tenderness - ANS pt's feelings (subjective) vs physician's assessment
(objective)

distress - ANS the doctor's judgement of discomfort

baseline - ANS an individual's normal state of being

What CAN scribes do? - ANS -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? - ANS -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? - ANS Manages ED pt flow

What does the ED Nurse do? - ANS Records medical Hx, symptoms, monitors pt, starts
IVs, administers medications, and assists with procedures.

What does the Unit Secretary do? - ANS Places physician's orders, answers phone
calls, pages other specialists/doctors, and organizes pt's paperwork.

What does the scribe do? - ANS Document pt's visit on behalf of the physician.

What is the ED flow? - ANS Walk in → triage → bed → physician assessment →
labs/rad/meds → results → MDM → diagnosis → consults → disposition

What are the 5 vital signs? - ANS -RR
-BP
-HR
-temp
-O2 sat

Level of acuity - ANS 5 (low) to 1 (high)

, What are all the parts of the chart? - ANS -HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition

What goes in each SOAP section? - ANS S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition

Pt says "high blood pressure," you write... - ANS hypertension (HTN)

Pt says "high cholesterol," you write... - ANS hyperlipidemia (HLD)

Pt says "diabetes," you write... - ANS diabetes mellitus (DM)

Pt says "I take pills for my diabets," you write... - ANS non-insulin dependent diabetes
mellitus (NIDDM)

Pt says "I take shots (insulin) for my diabetes," you write... - ANS insulin dependent
diabetes mellitus (IDDM)

Pt says "heart disease," you write... - ANS coronary artery disease (CAD)

Pt says "heart attack," you write... - ANS myocardial infarction (MI) and CAD

Pt says "heart failure," you write... - ANS congestive heart failure (CHF)

Pt says "irregular heartbeat," you write... - ANS atrial fibrillation (a fib) or arrhythmia

Pt says "murmur," you write... - ANS heart murmur

Pt says "abnormally fast/racing heartbeat," you write... - ANS supraventricular
tachycardia (SVT) or arrhythmia

Pt says "emphysema/chronic bronchitis," you write... - ANS chronic obstructive
pulmonary disease (COPD)

Pt says "blood clot in lung," you write... - ANS pulmonary embolism (PE)

Pt says "pneumonia," you write... - ANS pneumonia (PNA)

Pt says "reflux," you write... - ANS gastroesophageal reflux disease (GERD)