ScribeAmerica ED Final Exam Prep: Verified
Questions and Accurate Answers Guide
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)
Pt says "I take shots (insulin) for my diabetes," you write...
insulin dependent diabetes mellitus (IDDM)
Pt says "heart disease," you write...
coronary artery disease (CAD)
Pt says "heart attack," you write...
myocardial infarction (MI) and CAD
Pt says "heart failure," you write...
congestive heart failure (CHF)
Pt says "irregular heartbeat," you write...
atrial fibrillation (a fib) or arrhythmia
Pt says "murmur," you write...
heart murmur
Pt says "abnormally fast/racing heartbeat," you write...
supraventricular tachycardia (SVT) or arrhythmia
Pt says "emphysema/chronic bronchitis," you write...
chronic obstructive pulmonary disease (COPD)
Pt says "blood clot in lung," you write...
pulmonary embolism (PE)
Pt says "pneumonia," you write...
pneumonia (PNA)
Pt says "reflux," you write...
gastroesophageal reflux disease (GERD)
Questions and Accurate Answers Guide
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)
Pt says "I take shots (insulin) for my diabetes," you write...
insulin dependent diabetes mellitus (IDDM)
Pt says "heart disease," you write...
coronary artery disease (CAD)
Pt says "heart attack," you write...
myocardial infarction (MI) and CAD
Pt says "heart failure," you write...
congestive heart failure (CHF)
Pt says "irregular heartbeat," you write...
atrial fibrillation (a fib) or arrhythmia
Pt says "murmur," you write...
heart murmur
Pt says "abnormally fast/racing heartbeat," you write...
supraventricular tachycardia (SVT) or arrhythmia
Pt says "emphysema/chronic bronchitis," you write...
chronic obstructive pulmonary disease (COPD)
Pt says "blood clot in lung," you write...
pulmonary embolism (PE)
Pt says "pneumonia," you write...
pneumonia (PNA)
Pt says "reflux," you write...
gastroesophageal reflux disease (GERD)
