ScribeAmerica ED Final Exam UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS
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)
ANSWERS
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)
