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ScribeAmerica ED Final Exam _ WITH CORRECT ANSWERS.pdf
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9/2/24, 8:39 PMScribeAmerica ED Final Exam
Jeremiah
Terms in this set (180)
Chief Complaint the main reason for the pt's ED visit
pain vs tenderness pt's feelings (subjective) vs physician's assessment (objective)
distress the doctor's judgement of discomfort
baseline an individual's normal state of being
-Document Hx, PE, results, procedures, and physician consults
-Access and document lab results and radiology findings
What CAN scribes do?
-Locate and obtains PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
-Touch pts
-Write orders or Rxs
-Give verbal orders
What can scribes NOT do?
-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? Manages ED pt flow
Records medical Hx, symptoms, monitors pt, starts IVs, administers medications,
What does the ED Nurse do?
and assists with procedures.
Places physician's orders, answers phone calls, pages other specialists/doctors,
What does the Unit Secretary do?
and organizes pt's paperwork.
What does the scribe do? Document pt's visit on behalf of the physician.
Walk in → triage → bed → physician assessment → labs/rad/meds → results →
What is the ED flow?
MDM → diagnosis → consults → disposition
-RR
-BP
What are the 5 vital signs? -HR
-temp
-O2 sat
Level of acuity 5 (low) to 1 (high)
1/5
, 9/2/24, 8:39 PM
-HPI
-ROS
-Past Hx
What are all the parts of the chart?
-PE
-ED Course
-Disposition
S: HPI and ROS
O: PE and ED course
What goes in each SOAP section?
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write... hypertension (HTN)
Pt says "high cholesterol," you write... hyperlipidemia (HLD)
Pt says "diabetes," you write... diabetes mellitus (DM)
Pt says "I take pills for my diabets," you non-insulin dependent diabetes mellitus (NIDDM)
write...
Pt says "I take shots (insulin) for my diabetes," insulin dependent diabetes mellitus (IDDM)
you write...
Pt says "heart disease," you write... coronary artery disease (CAD)
Pt says "heart attack," you write... myocardial infarction (MI) and CAD
Pt says "heart failure," you write... congestive heart failure (CHF)
Pt says "irregular heartbeat," you write... atrial fibrillation (a fib) or arrhythmia
Pt says "murmur," you write... heart murmur
Pt says "abnormally fast/racing heartbeat," supraventricular tachycardia (SVT) or arrhythmia
you write...
Pt says "emphysema/chronic bronchitis," you chronic obstructive pulmonary disease (COPD)
write...
Pt says "blood clot in lung," you write... pulmonary embolism (PE)
Pt says "pneumonia," you write... pneumonia (PNA)
Pt says "reflux," you write... gastroesophageal reflux disease (GERD)
Pt says "ulcer," you write... gastric ulcer or peptic ulcer disease (PUD)
Pt says "kidney stones," you write... renal calculi
chronic renal failure (CRF) or end stage renal disease (ESRD) on dialysis; include
Pt says "I'm on dialysis," you write...
how often and when they go
G: how many pregnancies
Describe what G/P/A means. P: how many live births
A: how many abortions/miscarriages
Pt says "stroke," you write... CVA
Pt says "mini stroke," you write... TIA
Pt says "brain bleed," you write... hemorrhagic CVA
Pt says "I drink a lot," you write... ETOH abuse/alcoholism
Pt says "I do drugs," you write... substance abuse
Pt says "blood clot in leg," you write... LE DVT
2/5
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