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Scribe America ED Final Exam 100% Accurate!!
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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) Benig...

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  • November 25, 2024
  • 29
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • scribe america ed final exam 100 accurate
  • subjective vs objective answersfeeling vs fac

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  • Scribe America ED

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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

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