ScribeAmerica ED Final Exam ( Questions And Answers) Verified 100% Correct!! | 2024 update

Chief Complaint - the main reason for the pt's ED visit pain vs tenderness - pt's feelings (subjective) vs physician's assessment (objective) distress - the doctor's judgement of discomfort baseline - an individual's normal state of being What CAN scribes do? - -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? - -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? - Manages ED pt flow What does the ED Nurse do? - Records medical Hx, symptoms, monitors pt, starts IVs, administers medications, and assists with procedures. What does the Unit Secretary do? - Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes pt's paperwork.What does the scribe do? - Document pt's visit on behalf of the physician. What is the ED flow? - Walk in → triage → bed → physician assessment → labs/rad/meds → results → MDM → diagnosis → consults → disposition What are the 5 vital signs? - -RR -BP -HR -temp -O2 sat Level of acuity - 5 (low) to 1 (high) What are all the parts of the chart? - -HPI -ROS -Past Hx -PE -ED Course -Disposition What goes in each SOAP section? - S: HPI and ROS O: PE and ED course A: diagnosis P: plan and disposition Pt says "high blood pressure," you write... - hypertension (HTN) Pt says "high cholesterol," you write... - hyperlipidemia (HLD)Pt says "diabetes," you write... - diabetes mellitus (DM) Pt says "I take pills for my diabets," you write... - non-insulin dependent diabetes mellitus (NIDDM)