scribeamerica test/final exam 100%
Accurate!!
subjective - ANSWERSfeeling
objective - ANSWERSfact
medical decision making - ANSWERSthe physicians thought process
pain - ANSWERSpatients feeling
tenderness - ANSWERSphysician's assesment
benign - ANSWERSnormal nothing of concern
distress - ANSWERSdoctors judgment of discomfort
febrile - ANSWERSthe state of having a fever, concerning for infection
actue - ANSWERSnew onset, likely concerning
chronic - ANSWERSlong standing, not of direct concern
baseline - ANSWERSan individuals normal state of being
auscultation - ANSWERSlistening with stethoscope
palpation - ANSWERSthe act of pressing on an area
inpatient - ANSWERSadmitted to the hospital overnight
outpatient - ANSWERSseen and sent home the same day
what is a scribe - ANSWERSan emergency phyiscian scribe is an unlicensed person
perfoming documentation or other non-clinical tasks under the direction of a licensed
independent practitioner
charge nurse - ANSWERSmanages the ED patient flow
Mid level provider - ANSWERSnurse practiitioner (LNP) or physician assistant (PA) that
works under the supervison of a physician to diagnose and treat patients
,ed nurse - ANSWERSrecords medical histories, symptoms, monitors the pateints, starts
IVs, administeres meidaction and asssists with procedures
Respiratory therapists (RT) - ANSWERSadministers "breathing treatments" and assists
with managing a patients airways
ED tech - ANSWERShelps the nurse and assists with procedures
Unit Secretary - ANSWERSplaces physicians orders, answers phone calls, pages other
specialists/doctors/ and organizes the patients paperwork
scribe - ANSWERSdocuments the patients visit on behalf of the physician
differential diagnoses - ANSWERSbased on the H&P, the physician generates a list of
things that may be causing the patients subjective symptoms. the doctor then places
orders to rule out each differential
history of present illness (HPI) - ANSWERSthe story and context of the chief complaint
review of symptoms (ROS) - ANSWERSa head to toe list of postives and negatives
past history includes - ANSWERSPMHx, PSHx, SHx, FHx
physical examination (PE) - ANSWERSthe physician's objective findings
ED course - ANSWERSobjective results (Labs, imaging, re-evals, consults,
procedures,)
disposition - ANSWERSdischarge, admit, transfer
vital signs include - ANSWERSblood pressure, heart rate, respiratory rate, temperature,
and oxygen saturation
high blood pressure - ANSWERShypertension (HTN)
high cholesterol - ANSWERShyperlipidemia (HLD)
thyroid problem - ANSWERShypothyroidism or hyperthyroidism
diabetes - ANSWERSdiabetes mellitus (DM)
i only take pills for diabetes - ANSWERSnon-insulin dependent diabetes mellitus
(NIDDM)
i take shots for my diabetes - ANSWERSInsulin dependent diabetes mellitus (IDDM)
, heart disease - ANSWERScoronary artery disease (CAD)
heart attack - ANSWERSmyocardial infarction (MI) (will have CAD)
heart failure - ANSWERScongestive heart failure (CHF)
irregular heart beat - ANSWERSatrial fibrillation (A fib)
murmur - ANSWERSheart murmur
episodes of abnormally fast/racing heartbeat - ANSWERSsupraventricular tachycardia
(SVT)
asthma - ANSWERSjust asthma
emphysema/ Chronic bronchitis - ANSWERSchronic obstructive pulmonary disease
(COPD)
pneumonia - ANSWERSpneumonia (PNA)
reflux - ANSWERSgastroesophageal reflux disease (GERD)
ulcer - ANSWERSgastric ulcer or peptic ulcer disease
pancreatitis - ANSWERSpancreatitis
hepatitis - ANSWERShepatitis A, B or C
diverticulitis - ANSWERSdiverticulitis
Crohn's/ UC - ANSWERSCrohn's disease or ulcerative colitis
irritable bowel - ANSWERSirritable bowel syndrome (IBS)
bladder infection - ANSWERSurinary tract infection (UTI)
kidney infection - ANSWERSpyelonephritis (pyelo)
kidney stones - ANSWERSrenal calculi
i'm on dialysis - ANSWERSchronic renal failure (CRF) or end stage renal disease
(ESRD) on dialysis
enlarge prosteate - ANSWERSbenign prostate hypertrophy (BPH)
stroke - ANSWERScerebrovascular accident (CVA)
Accurate!!
subjective - ANSWERSfeeling
objective - ANSWERSfact
medical decision making - ANSWERSthe physicians thought process
pain - ANSWERSpatients feeling
tenderness - ANSWERSphysician's assesment
benign - ANSWERSnormal nothing of concern
distress - ANSWERSdoctors judgment of discomfort
febrile - ANSWERSthe state of having a fever, concerning for infection
actue - ANSWERSnew onset, likely concerning
chronic - ANSWERSlong standing, not of direct concern
baseline - ANSWERSan individuals normal state of being
auscultation - ANSWERSlistening with stethoscope
palpation - ANSWERSthe act of pressing on an area
inpatient - ANSWERSadmitted to the hospital overnight
outpatient - ANSWERSseen and sent home the same day
what is a scribe - ANSWERSan emergency phyiscian scribe is an unlicensed person
perfoming documentation or other non-clinical tasks under the direction of a licensed
independent practitioner
charge nurse - ANSWERSmanages the ED patient flow
Mid level provider - ANSWERSnurse practiitioner (LNP) or physician assistant (PA) that
works under the supervison of a physician to diagnose and treat patients
,ed nurse - ANSWERSrecords medical histories, symptoms, monitors the pateints, starts
IVs, administeres meidaction and asssists with procedures
Respiratory therapists (RT) - ANSWERSadministers "breathing treatments" and assists
with managing a patients airways
ED tech - ANSWERShelps the nurse and assists with procedures
Unit Secretary - ANSWERSplaces physicians orders, answers phone calls, pages other
specialists/doctors/ and organizes the patients paperwork
scribe - ANSWERSdocuments the patients visit on behalf of the physician
differential diagnoses - ANSWERSbased on the H&P, the physician generates a list of
things that may be causing the patients subjective symptoms. the doctor then places
orders to rule out each differential
history of present illness (HPI) - ANSWERSthe story and context of the chief complaint
review of symptoms (ROS) - ANSWERSa head to toe list of postives and negatives
past history includes - ANSWERSPMHx, PSHx, SHx, FHx
physical examination (PE) - ANSWERSthe physician's objective findings
ED course - ANSWERSobjective results (Labs, imaging, re-evals, consults,
procedures,)
disposition - ANSWERSdischarge, admit, transfer
vital signs include - ANSWERSblood pressure, heart rate, respiratory rate, temperature,
and oxygen saturation
high blood pressure - ANSWERShypertension (HTN)
high cholesterol - ANSWERShyperlipidemia (HLD)
thyroid problem - ANSWERShypothyroidism or hyperthyroidism
diabetes - ANSWERSdiabetes mellitus (DM)
i only take pills for diabetes - ANSWERSnon-insulin dependent diabetes mellitus
(NIDDM)
i take shots for my diabetes - ANSWERSInsulin dependent diabetes mellitus (IDDM)
, heart disease - ANSWERScoronary artery disease (CAD)
heart attack - ANSWERSmyocardial infarction (MI) (will have CAD)
heart failure - ANSWERScongestive heart failure (CHF)
irregular heart beat - ANSWERSatrial fibrillation (A fib)
murmur - ANSWERSheart murmur
episodes of abnormally fast/racing heartbeat - ANSWERSsupraventricular tachycardia
(SVT)
asthma - ANSWERSjust asthma
emphysema/ Chronic bronchitis - ANSWERSchronic obstructive pulmonary disease
(COPD)
pneumonia - ANSWERSpneumonia (PNA)
reflux - ANSWERSgastroesophageal reflux disease (GERD)
ulcer - ANSWERSgastric ulcer or peptic ulcer disease
pancreatitis - ANSWERSpancreatitis
hepatitis - ANSWERShepatitis A, B or C
diverticulitis - ANSWERSdiverticulitis
Crohn's/ UC - ANSWERSCrohn's disease or ulcerative colitis
irritable bowel - ANSWERSirritable bowel syndrome (IBS)
bladder infection - ANSWERSurinary tract infection (UTI)
kidney infection - ANSWERSpyelonephritis (pyelo)
kidney stones - ANSWERSrenal calculi
i'm on dialysis - ANSWERSchronic renal failure (CRF) or end stage renal disease
(ESRD) on dialysis
enlarge prosteate - ANSWERSbenign prostate hypertrophy (BPH)
stroke - ANSWERScerebrovascular accident (CVA)
