ScribeAmerica ED Final Exam questions and
answers 2025\2026 A+ Grade
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)
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
A: diagnosis
P: plan and disposition
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)
answers 2025\2026 A+ Grade
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)
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
A: diagnosis
P: plan and disposition
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)
