Scribe U Final Exam Questions with 100% Correct Answers 2024

Scribe U Final Exam Questions with 100% Correct Answers 2024 What can a scribe do? - answerdocument history, PE, results, procedures, radiology/lab results, procedure, display x-rays, locate/ obtain MH What can a scribe not do? - answertouch patients, write order/rx, give evrbal orders, sign/authenticate, handle bodily/fluids/specimen Acute means - answernew onset, likely concerning chronic - answerlong-stanidng, not of direct concern Do we put PE/LAB RESULTS/RADIOLOGY FINDS IN THE HPI? - answerNEVER! What goes in the HPI? - answerCC and anything relevant to the CC What does the ROS include? - answerit is a full body check so will include the CC (chief complaint) and pertinent associated sx plus anything else going on that we did not mention in the HPI since it was not related to the CC. What goes into the assessment? - answerage/sex; Dx, DDX, conclusion. Summary of HPI content (CC and onset) ○ PMHx (if relevant) ○ Summary of PE ○ Summary of Results (Who, When, and Why?) ○ Prognosis What is the assessment? - answerusually a "note for themselves" for provider What are two requirements for a result to be included in the assessment? - answerresult must be new and relevant to Dx How do you summarize a result? - answer1. name of test 2. result of test 3. why the test was ordered What does the plan include? - answer1. treatment for dx 2. rx ordered today 3. studies, imaging, tests ordered today 4. follow-up with other health care pro