Scribe America Final Exam Review Questions (Courses 1-5)

Scribe America Final Exam Review Questions (Courses 1-5) Fill in the blanks for ED Flow: Walk in Blank 1 Bed Physician Assessment Lab/Rad/Meds Results MDM Diagnosis Consults Blank 2 Triage, Disposition What are the 3 disposition options? Discharge, Admit, Transfer What are the 5 vital signs? Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation The HPI and ROS are what type of information (subjective or objective)? subjective The Physical Exam is what type of information (subjective or objective)? objective While evaluating a patient complaining of chest pain, your physician tells you that the heart sounds are normal. Would you document it in the HPI, ROS, or PE? PE Would you be contradicting yourself if you wrote "The patient has abdominal pain" in the HPI, but then later in the physical exam documented "The abdomen is nontender." Why or why not? No, because the patient stating they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding. What is the difference between the HPI and ROS? HPI focuses on the details related to their chief complaint. ROS is a head-to-toe checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have. What does disposition (dispo) mean? The patient's destination after they leave the Emergency Department. What subcategories are included within the Past History section of the template? PMHx (Past Medical History- HTN, DM, HLD, CAD, MI.......), PSHx, (Past Surgical History- Appendectomy, Cholecystectomy, CABG......)FHx, (Family History- Hx of CAD 55 y/o....)SHx, (Social History- ETOH, Smoking, Drug Abuse, Occupation.....) What is the abbreviation for a heart attack? MI- Myocardial Infarction What is the abbreviation for high blood pressure? HTN- Hypertension What is the medical term for acid reflux? GERD- Gastroesophageal Reflux Disease What is the medical term for stroke? CVA- Cerebrovascular Accident What is the term for gallbladder removal? Cholecystectomy What does NKDA stand for? No Known Drug Allergies What is the medical term for redness?