Scribe America ED Final Exam 100%
Accurate!!
Subjective vs. Objective - ANSWERSFeeling vs. Fact
Chief Complaint (CC) - ANSWERSThe main reason for the patient's ED visit
Medical Decision Making (MDM) - ANSWERSThe physician's thought process
Pain vs. Tenderness - ANSWERSpatient's feeling vs. physician's assessment
(subjective)
Benign - ANSWERSNormal, nothing of concern
Distress - ANSWERSThe doctor's judgement of discomfort (objective)
Febrile - ANSWERSThe state of having a fever, concerning for infection
Acute - ANSWERSNew onset, likely concerning
Chronic - ANSWERSLong-standing, not of direct concern (90 days- 3mo)
Baseline - ANSWERSAn individual's normal state of being
Auscultation - ANSWERSListening with a stethoscope
Palpation - ANSWERSThe act of pressing on an area (by the doctor)
Inpatient - ANSWERSAdmitted to the hospital overnight
Outpatient - ANSWERSSeen and sent home the same day
Scribes CAN - ANSWERS1. Document the history, physical exam, results, procedures,
and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT - ANSWERS1. Touch patients
2. Write orders or prescriptions
3. Give verbal orders
4. Partake in any activity that may affect patient health or outcome
,5. Sign or authenticate any chart or record
6. Handle bodily fluids or specimens
People in the Emergency Department - ANSWERS1. Charge Nurse: manages the ED
patient flow.
2. Mid-level provider: Nurse Practitioner (NP) or Physician Assistant (PA) that works
under the supervision of a physician to diagnose and treat patients
3. ED Nurse: Records medical histories, symptoms, monitors the patient, starts IVs,
administers medications, and assists with procedures
4. Respiratory Therapist (RT) : Administers "breathing treatments" and assists with
managing a patient's airway
5. ED tech: helps the nurse and assists with procedures
6. Unit Secretary: Places physicians orders, answers phone calls, pages other
specialist/doctors, and organizes the patient's paperwork
7. Scribe: documents the patient's visit on behalf of the physician
Emergency Department Flow - ANSWERS1. Check in and chief complaint
2. Physician assessment
3. Objective orders and results
4. Medical decision making
5. Disposition
DDx - ANSWERSDifferential diagnosis
General Documentation Template - ANSWERSSubjective complaints:HPI, ROS, Past
History
Objective evaluation: PE, ED course,Disposition
HPI - ANSWERShistory of present illness; story and context of chief complaint
Review of Systems (ROS) - ANSWERSA head-to-toe list of positives and negatives
Past History - ANSWERSPMHx, PSHx, SHx, FHx
PMHx - ANSWERSpast medical history
PSHx - ANSWERSpast surgical history
SHx - ANSWERSsocial history
FHx - ANSWERSfamily history
Physical Examination (PE) - ANSWERSThe physician's objective findings
ED Course - ANSWERSobjective results (labs, imaging, re-evals, consults, procedures)
, Disposition - ANSWERSDischarge, Admit, Transfer
Patient says: high blood pressure - ANSWERSScribe writes: Hypertension (HTN)
HTN - ANSWERSHypertension
Patient says: high cholesterol - ANSWERSScribe writes: Hyperlipidemia (HLD)
HLD - ANSWERSHyperlipidemia
Patient says: thyroid problem - ANSWERSScribe writes: Usually Hypothyroidism,
sometimes Hyperthyroidism
Patient says: diabetes - ANSWERSScribe writes: Diabetes Mellitus (DM)
DM - ANSWERSdiabetes mellitus
Patient says: I only take pills for my diabetes - ANSWERSScribe writes: Non-Insulin
Dependent Diabetes Mellitus (NIDDM)
NIDDM - ANSWERSnon-insulin-dependent diabetes mellitus (type 2)
Patient says: I take shots (insulin) for my diabetes - ANSWERSScribe writes: Insulin
Dependent Diabetes Mellitus (IDDM)
IDDM - ANSWERSinsulin-dependent diabetes mellitus (type 1)
Patient says: Heart Disease - ANSWERSScribe writes: Usually Coronary Artery
Disease (CAD)
CAD - ANSWERScoronary artery disease
Patient says: Heart Attack - ANSWERSScribe writes: Myocardial Infarction (MI) and
CAD
MI - ANSWERSmyocardial infarction
Patient says: Heart Failure - ANSWERSScribe Writes: Congestive Heart Failure (CHF)
CHF - ANSWERScongestive heart failure
Patient says: irregular heartbeat - ANSWERSScribe Writes: Atrial Fibrillation (A-Fib)
A Fib - ANSWERSatrial fibrillation
Accurate!!
Subjective vs. Objective - ANSWERSFeeling vs. Fact
Chief Complaint (CC) - ANSWERSThe main reason for the patient's ED visit
Medical Decision Making (MDM) - ANSWERSThe physician's thought process
Pain vs. Tenderness - ANSWERSpatient's feeling vs. physician's assessment
(subjective)
Benign - ANSWERSNormal, nothing of concern
Distress - ANSWERSThe doctor's judgement of discomfort (objective)
Febrile - ANSWERSThe state of having a fever, concerning for infection
Acute - ANSWERSNew onset, likely concerning
Chronic - ANSWERSLong-standing, not of direct concern (90 days- 3mo)
Baseline - ANSWERSAn individual's normal state of being
Auscultation - ANSWERSListening with a stethoscope
Palpation - ANSWERSThe act of pressing on an area (by the doctor)
Inpatient - ANSWERSAdmitted to the hospital overnight
Outpatient - ANSWERSSeen and sent home the same day
Scribes CAN - ANSWERS1. Document the history, physical exam, results, procedures,
and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
Scribes CANNOT - ANSWERS1. Touch patients
2. Write orders or prescriptions
3. Give verbal orders
4. Partake in any activity that may affect patient health or outcome
,5. Sign or authenticate any chart or record
6. Handle bodily fluids or specimens
People in the Emergency Department - ANSWERS1. Charge Nurse: manages the ED
patient flow.
2. Mid-level provider: Nurse Practitioner (NP) or Physician Assistant (PA) that works
under the supervision of a physician to diagnose and treat patients
3. ED Nurse: Records medical histories, symptoms, monitors the patient, starts IVs,
administers medications, and assists with procedures
4. Respiratory Therapist (RT) : Administers "breathing treatments" and assists with
managing a patient's airway
5. ED tech: helps the nurse and assists with procedures
6. Unit Secretary: Places physicians orders, answers phone calls, pages other
specialist/doctors, and organizes the patient's paperwork
7. Scribe: documents the patient's visit on behalf of the physician
Emergency Department Flow - ANSWERS1. Check in and chief complaint
2. Physician assessment
3. Objective orders and results
4. Medical decision making
5. Disposition
DDx - ANSWERSDifferential diagnosis
General Documentation Template - ANSWERSSubjective complaints:HPI, ROS, Past
History
Objective evaluation: PE, ED course,Disposition
HPI - ANSWERShistory of present illness; story and context of chief complaint
Review of Systems (ROS) - ANSWERSA head-to-toe list of positives and negatives
Past History - ANSWERSPMHx, PSHx, SHx, FHx
PMHx - ANSWERSpast medical history
PSHx - ANSWERSpast surgical history
SHx - ANSWERSsocial history
FHx - ANSWERSfamily history
Physical Examination (PE) - ANSWERSThe physician's objective findings
ED Course - ANSWERSobjective results (labs, imaging, re-evals, consults, procedures)
, Disposition - ANSWERSDischarge, Admit, Transfer
Patient says: high blood pressure - ANSWERSScribe writes: Hypertension (HTN)
HTN - ANSWERSHypertension
Patient says: high cholesterol - ANSWERSScribe writes: Hyperlipidemia (HLD)
HLD - ANSWERSHyperlipidemia
Patient says: thyroid problem - ANSWERSScribe writes: Usually Hypothyroidism,
sometimes Hyperthyroidism
Patient says: diabetes - ANSWERSScribe writes: Diabetes Mellitus (DM)
DM - ANSWERSdiabetes mellitus
Patient says: I only take pills for my diabetes - ANSWERSScribe writes: Non-Insulin
Dependent Diabetes Mellitus (NIDDM)
NIDDM - ANSWERSnon-insulin-dependent diabetes mellitus (type 2)
Patient says: I take shots (insulin) for my diabetes - ANSWERSScribe writes: Insulin
Dependent Diabetes Mellitus (IDDM)
IDDM - ANSWERSinsulin-dependent diabetes mellitus (type 1)
Patient says: Heart Disease - ANSWERSScribe writes: Usually Coronary Artery
Disease (CAD)
CAD - ANSWERScoronary artery disease
Patient says: Heart Attack - ANSWERSScribe writes: Myocardial Infarction (MI) and
CAD
MI - ANSWERSmyocardial infarction
Patient says: Heart Failure - ANSWERSScribe Writes: Congestive Heart Failure (CHF)
CHF - ANSWERScongestive heart failure
Patient says: irregular heartbeat - ANSWERSScribe Writes: Atrial Fibrillation (A-Fib)
A Fib - ANSWERSatrial fibrillation
