Scribe America ED Final Exam Study Questions with
Correct Detailed Answers 2025
/ Chief Complaint - Answer-the main reason for the pt's ED visit
/.pain vs tenderness - Answer-pt's feelings (subjective) vs physician's assessment
(objective)
/.distress - Answer-the doctor's judgement of discomfort
/.baseline - Answer-an individual's normal state of being
/.What CAN scribes do? - 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? - 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? - Answer-Manages ED pt flow
/.What does the ED Nurse do? - Answer-Records medical Hx, symptoms, monitors pt,
starts IVs, administers medications, and assists with procedures.
/.What does the Unit Secretary do? - Answer-Places physician's orders, answers phone
calls, pages other specialists/doctors, and organizes pt's paperwork.
/.What does the scribe do? - Answer-Document pt's visit on behalf of the physician.
/.What is the ED flow? - Answer-Walk in → triage → bed → physician assessment →
labs/rad/meds → results → MDM → diagnosis → consults → disposition
/.What are the 5 vital signs? - Answer--RR
-BP
-HR
-temp
-O2 sat
, /.Level of acuity - Answer-5 (low) to 1 (high)
/.What are all the parts of the chart? - Answer--HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
/.What goes in each SOAP section? - Answer-S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
/.Pt says "high blood pressure," you write... - Answer-hypertension (HTN)
/.Pt says "high cholesterol," you write... - Answer-hyperlipidemia (HLD)
/.Pt says "diabetes," you write... - Answer-diabetes mellitus (DM)
/.Pt says "I take pills for my diabets," you write... - Answer-non-insulin dependent
diabetes mellitus (NIDDM)
/.Pt says "I take shots (insulin) for my diabetes," you write... - Answer-insulin dependent
diabetes mellitus (IDDM)
/.Pt says "heart disease," you write... - Answer-coronary artery disease (CAD)
/.Pt says "heart attack," you write... - Answer-myocardial infarction (MI) and CAD
/.Pt says "heart failure," you write... - Answer-congestive heart failure (CHF)
/.Pt says "irregular heartbeat," you write... - Answer-atrial fibrillation (a fib) or arrhythmia
/.Pt says "murmur," you write... - Answer-heart murmur
/.Pt says "abnormally fast/racing heartbeat," you write... - Answer-supraventricular
tachycardia (SVT) or arrhythmia
/.Pt says "emphysema/chronic bronchitis," you write... - Answer-chronic obstructive
pulmonary disease (COPD)
/.Pt says "blood clot in lung," you write... - Answer-pulmonary embolism (PE)
/.Pt says "pneumonia," you write... - Answer-pneumonia (PNA)
Correct Detailed Answers 2025
/ Chief Complaint - Answer-the main reason for the pt's ED visit
/.pain vs tenderness - Answer-pt's feelings (subjective) vs physician's assessment
(objective)
/.distress - Answer-the doctor's judgement of discomfort
/.baseline - Answer-an individual's normal state of being
/.What CAN scribes do? - 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? - 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? - Answer-Manages ED pt flow
/.What does the ED Nurse do? - Answer-Records medical Hx, symptoms, monitors pt,
starts IVs, administers medications, and assists with procedures.
/.What does the Unit Secretary do? - Answer-Places physician's orders, answers phone
calls, pages other specialists/doctors, and organizes pt's paperwork.
/.What does the scribe do? - Answer-Document pt's visit on behalf of the physician.
/.What is the ED flow? - Answer-Walk in → triage → bed → physician assessment →
labs/rad/meds → results → MDM → diagnosis → consults → disposition
/.What are the 5 vital signs? - Answer--RR
-BP
-HR
-temp
-O2 sat
, /.Level of acuity - Answer-5 (low) to 1 (high)
/.What are all the parts of the chart? - Answer--HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
/.What goes in each SOAP section? - Answer-S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
/.Pt says "high blood pressure," you write... - Answer-hypertension (HTN)
/.Pt says "high cholesterol," you write... - Answer-hyperlipidemia (HLD)
/.Pt says "diabetes," you write... - Answer-diabetes mellitus (DM)
/.Pt says "I take pills for my diabets," you write... - Answer-non-insulin dependent
diabetes mellitus (NIDDM)
/.Pt says "I take shots (insulin) for my diabetes," you write... - Answer-insulin dependent
diabetes mellitus (IDDM)
/.Pt says "heart disease," you write... - Answer-coronary artery disease (CAD)
/.Pt says "heart attack," you write... - Answer-myocardial infarction (MI) and CAD
/.Pt says "heart failure," you write... - Answer-congestive heart failure (CHF)
/.Pt says "irregular heartbeat," you write... - Answer-atrial fibrillation (a fib) or arrhythmia
/.Pt says "murmur," you write... - Answer-heart murmur
/.Pt says "abnormally fast/racing heartbeat," you write... - Answer-supraventricular
tachycardia (SVT) or arrhythmia
/.Pt says "emphysema/chronic bronchitis," you write... - Answer-chronic obstructive
pulmonary disease (COPD)
/.Pt says "blood clot in lung," you write... - Answer-pulmonary embolism (PE)
/.Pt says "pneumonia," you write... - Answer-pneumonia (PNA)
