Final Exam ED Scribe America And Verified Answers 2024.

What are the necessary elements to include in the HPI, ROS, PMH/FH/SH, and PE to qualify for level 5 billing? - Answer HPI: 4 elements ROS: 10 systems PMH/FH/SH: 2 of 3 PE: 8 systems (excluding head and neck) what is medical decision making? - Answer the physician's thought process (MDM) benign (def) - Answer nothing of concern febrile (def) - Answer the state of having a fever, concerning for infection acute (def) - Answer new onset, likely concerning distress (def) - Answer the doctor's judgement of discomfort H&P - Answer history and physical What are the steps of ED flow (in detail)? - Answer Enter--triage--bed placement--nurse assessment--H&P (HPI, past history, PE)--Dif Dx--physician orders (labs, imaging, procedures, meds)-- results & ED course (re-evaluations, consult specialists)--Final Dx (MDM, r/o DDx, reach final Dx)--disposition What is the general documentation order? - Answer HPI, ROS, Past History, PE, ED course, Disposition What does the ED course consist of? - Answer labs, imaging, procedures, consultations, medications, events, and re-evaluations (objective results)