Scribe America Final Exam Review Questions and Answers (Courses 1-5) Fill in the blanks for ED Flow: Walk in > *Blank 1* > Bed > Physician Assessment > Lab/Rad/Meds > Results > MDM > Diagnosis > Consults > *Blank 2* - correct answer ✅Triage, Disposition
What are the 3 disposition options? - correct answer ✅Discharge, Admit, Transfer
What are the 5 vital signs? - correct answer ✅Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation
The HPI and ROS are what type of information (subjective or objective)?
- correct answer ✅subjective
The Physical Exam is what type of information (subjective or objective)? - correct answer ✅objective
While evaluating a patient complaining of chest pain, your physician tells you that the heart sounds are normal. Would you document it in the HPI, ROS, or PE? - correct answer ✅PE Scribe America Final Exam Review Questions and Answers (Courses 1-5) Would you be contradicting yourself if you wrote "The patient has abdominal pain" in the HPI, but then later in the physical exam documented "The abdomen is nontender." Why or why not? - correct answer ✅No, because the patient stating they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding.
What is the difference between the HPI and ROS? - correct answer ✅HPI focuses on the details related to their chief complaint. ROS is a head-to-toe checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have.
What does disposition (dispo) mean? - correct answer ✅The patient's destination after they leave the Emergency Department.
What subcategories are included within the Past History section of the template? - correct answer ✅PMHx (Past Medical History- HTN, DM, HLD, CAD, MI.......), PSHx, (Past Surgical History- Appendectomy, Cholecystectomy, CABG......)FHx, (Family History- Hx of CAD < 55 y/o....)SHx, (Social History- ETOH, Smoking, Drug Abuse, Occupation.....)
What is the abbreviation for a heart attack? - correct answer ✅MI- Myocardial Infarction Scribe America Final Exam Review Questions and Answers (Courses 1-5) What is the abbreviation for high blood pressure? - correct answer ✅HTN- Hypertension
What is the medical term for acid reflux? - correct answer ✅GERD- Gastroesophageal Reflux Disease
What is the medical term for stroke? - correct answer ✅CVA- Cerebrovascular Accident
What is the term for gallbladder removal? - correct answer ✅Cholecystectomy
What does NKDA stand for? - correct answer ✅No Known Drug Allergies
What is the medical term for redness? - correct answer ✅Erythema
What is the medical term for bruising? - correct answer ✅Ecchymosis Scribe America Final Exam Review Questions and Answers (Courses 1-5) If the doctor says the exam was "benign", what does that mean? - correct answer ✅Normal- Nothing of concern
What is CAD? - correct answer ✅Coronary Artery Disease.
What other past histories would suggest that a patient has CAD? - correct answer ✅MI, Angina, CABG, Stent, Angioplasty
Does a PMHx of CVA mean the patient has CAD? - correct answer ✅No
Does a surgical history of angioplasty mean the patient has CAD? - correct answer ✅Yes
Explain the difference between CAD and an MI. - correct answer ✅CAD is a broad term for heart disease. MI is included in CAD. It's an active heart attack.
If someone has a PMHx of A - correct answer ✅Fib or CHF, do they also have CAD?- No
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