ScribeAmerica ED Final Exam
Chief Complaint - Correct answer-the main reason for the pt's ED visit
pain vs tenderness - Correct answer-pt's feelings (subjective) vs physician's
assessment (objective)
distress - Correct answer-the doctor's judgement of discomfort
baseline - Correct answer-an individual's normal state of being
What CAN scribes do? - Correct answer--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? - Correct answer--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? - Correct answer-Manages ED pt flow
What does the ED Nurse do? - Correct answer-Records medical Hx, symptoms,
monitors pt, starts IVs, administers medications, and assists with procedures.
What does the Unit Secretary do? - Correct answer-Places physician's orders, answers
phone calls, pages other specialists/doctors, and organizes pt's paperwork.
What does the scribe do? - Correct answer-Document pt's visit on behalf of the
physician.
What is the ED flow? - Correct answer-Walk in → triage → bed → physician
assessment → labs/rad/meds → results → MDM → diagnosis → consults → disposition
What are the 5 vital signs? - Correct answer--RR
-BP
-HR
-temp
-O2 sat
, Level of acuity - Correct answer-5 (low) to 1 (high)
What are all the parts of the chart? - Correct answer--HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
What goes in each SOAP section? - Correct answer-S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... - Correct answer-hypertension (HTN)
Pt says "high cholesterol," you write... - Correct answer-hyperlipidemia (HLD)
Pt says "diabetes," you write... - Correct answer-diabetes mellitus (DM)
Pt says "I take pills for my diabets," you write... - Correct answer-non-insulin dependent
diabetes mellitus (NIDDM)
Pt says "I take shots (insulin) for my diabetes," you write... - Correct answer-insulin
dependent diabetes mellitus (IDDM)
Pt says "heart disease," you write... - Correct answer-coronary artery disease (CAD)
Pt says "heart attack," you write... - Correct answer-myocardial infarction (MI) and CAD
Pt says "heart failure," you write... - Correct answer-congestive heart failure (CHF)
Pt says "irregular heartbeat," you write... - Correct answer-atrial fibrillation (a fib) or
arrhythmia
Pt says "murmur," you write... - Correct answer-heart murmur
Pt says "abnormally fast/racing heartbeat," you write... - Correct answer-
supraventricular tachycardia (SVT) or arrhythmia
Pt says "emphysema/chronic bronchitis," you write... - Correct answer-chronic
obstructive pulmonary disease (COPD)
Pt says "blood clot in lung," you write... - Correct answer-pulmonary embolism (PE)
Pt says "pneumonia," you write... - Correct answer-pneumonia (PNA)
Chief Complaint - Correct answer-the main reason for the pt's ED visit
pain vs tenderness - Correct answer-pt's feelings (subjective) vs physician's
assessment (objective)
distress - Correct answer-the doctor's judgement of discomfort
baseline - Correct answer-an individual's normal state of being
What CAN scribes do? - Correct answer--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? - Correct answer--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? - Correct answer-Manages ED pt flow
What does the ED Nurse do? - Correct answer-Records medical Hx, symptoms,
monitors pt, starts IVs, administers medications, and assists with procedures.
What does the Unit Secretary do? - Correct answer-Places physician's orders, answers
phone calls, pages other specialists/doctors, and organizes pt's paperwork.
What does the scribe do? - Correct answer-Document pt's visit on behalf of the
physician.
What is the ED flow? - Correct answer-Walk in → triage → bed → physician
assessment → labs/rad/meds → results → MDM → diagnosis → consults → disposition
What are the 5 vital signs? - Correct answer--RR
-BP
-HR
-temp
-O2 sat
, Level of acuity - Correct answer-5 (low) to 1 (high)
What are all the parts of the chart? - Correct answer--HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
What goes in each SOAP section? - Correct answer-S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... - Correct answer-hypertension (HTN)
Pt says "high cholesterol," you write... - Correct answer-hyperlipidemia (HLD)
Pt says "diabetes," you write... - Correct answer-diabetes mellitus (DM)
Pt says "I take pills for my diabets," you write... - Correct answer-non-insulin dependent
diabetes mellitus (NIDDM)
Pt says "I take shots (insulin) for my diabetes," you write... - Correct answer-insulin
dependent diabetes mellitus (IDDM)
Pt says "heart disease," you write... - Correct answer-coronary artery disease (CAD)
Pt says "heart attack," you write... - Correct answer-myocardial infarction (MI) and CAD
Pt says "heart failure," you write... - Correct answer-congestive heart failure (CHF)
Pt says "irregular heartbeat," you write... - Correct answer-atrial fibrillation (a fib) or
arrhythmia
Pt says "murmur," you write... - Correct answer-heart murmur
Pt says "abnormally fast/racing heartbeat," you write... - Correct answer-
supraventricular tachycardia (SVT) or arrhythmia
Pt says "emphysema/chronic bronchitis," you write... - Correct answer-chronic
obstructive pulmonary disease (COPD)
Pt says "blood clot in lung," you write... - Correct answer-pulmonary embolism (PE)
Pt says "pneumonia," you write... - Correct answer-pneumonia (PNA)
