Scribe America ED Final Exam Questions and Answers (Latest Update 2023/2024) 100% Verified

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. 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 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 "reflux," you write... - Correct answer-gastroesophageal reflux disease (GERD) Pt says "ulcer," you write... - Correct answer-gastric ulcer or peptic ulcer disease (PUD) Pt says "kidney stones," you write... - Correct answer-renal calculi Pt says "I'm on dialysis," you write... - Correct answer-chronic renal failure (CRF) or end stage renal disease (ESRD) on dialysis; include how often and when they go Describe what G/P/A means. - Correct answer-G: how many pregnancies P: how many live births A: how many abortions/miscarriages Pt says "stroke," you write... - Correct answer-CVA Pt says "mini stroke," you write... - Correct answer-TIA Pt says "brain bleed," you write... - Correct answer-hemorrhagic CVA Pt says "I drink a lot," you write... - Correct answer-ETOH abuse/alcoholism Pt says "I do drugs," you write... - Correct answer-substance abuse Pt says "blood clot in leg," you write... - Correct answer-LE DVT Pt says "bulge in my aorta/triple A," you write... - Correct answer-abdominal aortic aneurysm (AAA) Pt says "tonsils removed," you write... - Correct answer-tonsillectomy Pt says "heart bypass," you write... - Correct answer-coronary artery bypass graft (CABG) w/ PMHx of CAD Pt says "breast removal," you write... - Correct answer-mastectomy Pt says "stomach stapled," you write... - Correct answer-gastric bypass Pt says "kidney removed," you write... - Correct answer-nephrectomy Pt says "uterus removed," you write... - Correct answer-hysterectomy (partial or total) Pt says "tubes tied," you write... - Correct answer-tubal ligation (f) or vasectomy (m) What is it called when a medication causes a non-true allergy? - Correct answer- adverse reaction What are the 3 routes of drug administration? - Correct answer--oral -inhaled -injected What are the 3 types of dispositions? - Correct answer--discharged -admitted -transferred to another facility/dept