Course 1: Welcome and Patient Health History

Question 1

Scribe Role

Answer 1

Present during all data gathering and chart documentation; Responsibility is to update the Electronic Health Record (EHR) for the provider

Question 2

Scribes CAN…

Answer 2

Document the history, physical exam, results procedures, and consults; Access and document laboratory results and radiology findings; Access and display X-rays for the physician to review; Locate and obtain medical history, previous charts, and past results; Record physician interpretations of X-rays and EKG/ECGs

Question 3

Scribes CANNOT…

Answer 3

Touch patients; Write orders or prescriptions; Give verbal orders; Sign or authenticate any chart or record (on behalf of the provider); Handle bodily fluids or specimens

Question 4

Who do scribes work with?

Answer 4

Mid-level provider, Charge nurse, Nurse, Tech, Respiratory therapist (RT), Unit secretary

Question 5

Mid-Level Provider

Answer 5

Licensed nurse practitioner (NP) or physician assistant (PA)

Question 6

Charge Nurse

Answer 6

Manages ED patient flow

Question 7

Nurse

Answer 7

Records medical histories and symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures

Question 8

Tech

Answer 8

Helps the nurse/provider and assists with procedures

Question 9

Respiratory Therapist (RT)

Answer 9

Administers breathing treatments and assists with managing a patient’s airway

Question 10

Unit Secretary

Answer 10

Answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork

Question 11

ED Flow

Answer 11

1. Check-in and triage
2. History and physical
3. Differential diagnosis
4. Orders and treatment
5. Medical decision making
6. Disposition

Question 12

Triage

Answer 12

Chief complaint (CC), vital signs, level of acuity

Question 13

Vital signs

Answer 13

1. Heart rate/HR (bpm)
2. Blood pressure/BP (mm Hg)
3. Respiratory rate/RR
4. Temperature/T (°F/°C)
5. Oxygen saturation/SaO2 (%)

Question 14

Level of Acuity

Answer 14

Measures urgency of a case; 1 (high) to 5 (low)

Question 15

Nurse Assessment

Answer 15

Confirm chief complaint; brief past medical history; current medications; allergies

Question 16

Physician: History and Physical (H&P)

Answer 16

History of present illness (HPI); Review of systems (ROS); Past history (medical, surgical, family, social); Physical exam (PE)

Question 17

Physician: Differential Diagnoses (DDx)

Answer 17

Based on the history and physical, the physician generates a list of possible diagnoses and then places orders to rule out each diagnosis

Question 18

Physician: Orders and Treatment

Answer 18

Laboratory studies, imaging studies, procedures, medications

Question 19

Laboratory studies

Answer 19

Blood work, urinalysis, microscopy, cultures

Question 20

Imaging studies

Answer 20

EKG, X-ray, CT, ultrasound

Question 21

Procedures

Answer 21

Sutures, joint reduction, splints

Question 22

Medications

Answer 22

Antiemetics, analgesics, vasodilators, diuretics, antibiotics

Question 23

Physician: Medical Decision Making (MDM)

Answer 23

Physician formulates a diagnosis or treatment plan by considering the history and physical, past medical record, laboratory results, radiology results, and consults with specialists

Question 24

Physician: Disposition

Answer 24

Discharged to home, discharged to nursing facility, admitted, transferred, left against medical advice (AMA), expired

Question 25

Medical chart layout

Answer 25

1. History of present illness (HPI) 2. Review of systems (ROS) 3. Past history 4. Physical examination (PE) 5. ED course 6. Diagnosis and disposition

Question 26

Patient says high blood pressure

Answer 26

Hypertension (HTN)

Question 27

Patient says high cholesterol

Answer 27

Hyperlipidemia (HLD)

Question 28

Patient says diabetes

Answer 28

Diabetes Mellitus (DM)

Question 29

Patient says “I only take pills for my diabetes”

Answer 29

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Question 30

Patient says “I take shots for my diabetes”

Answer 30

Insulin Dependent Diabetes Mellitus (IDDM)

Question 31

Patient says heart disease

Answer 31

Coronary Artery Disease (CAD)

Question 32

Patient says heart attack

Answer 32

Myocardial Infarction (MI) and Coronary Artery Disease (CAD)

Question 33

Patient says heart failure

Answer 33

Congestive Heart Failure (CHF)

Question 34

Patient says irregular heartbeat

Answer 34

Arrhythmia

Question 35

Patient says asthma

Answer 35

Asthma

Question 36

Patient says emphysema or chronic bronchitis

Answer 36

Chronic Obstructive Pulmonary Disease (COPD)

Question 37

Patient says blood clot in lung

Answer 37

Pulmonary Embolism (PE)

Question 38

Patient says pneumonia

Answer 38

Pneumonia (PNA)

Question 39

Patient says reflux

Answer 39

Gastroesophageal Reflux Disease (GERD)

Question 40

Patient says ulcers

Answer 40

Gastric Ulcer or Peptic Ulcer Disease (PUD)

Question 41

Patient says pancreatitis

Answer 41

Pancreatitis

Question 42

Patient says hepatitis

Answer 42

Hepatitis

Question 43

Patient says irritable bowel

Answer 43

Irritable Bowel Syndrome (IBS)

Question 44

Patient says bladder infection

Answer 44

Urinary Tract Infection (UTI)

Question 45

Patient says kidney infection

Answer 45

Pyelonephritis

Question 46

Patient says kidney stones

Answer 46

Renal Calculi

Question 47

Patient says “I'm on dialysis”

Answer 47

Chronic Kidney Disease (CKD) on dialysis

Question 48

Patient says enlarged prostate

Answer 48

Benign Prostatic Hyperplasia (BPH)

Question 49

GPA

Answer 49

Gravida: Number of total pregnancies Para: Number of successful pregnancies Abortus: Number of unsuccessful pregnancies

Question 50

Patient says stroke

Answer 50

Cerebrovascular Accident (CVA)

Question 51

Patient says blockage in the brain

Answer 51

Ischemic CVA

Question 52

Patient says brain bleed

Answer 52

Hemorrhagic CVA

Question 53

Patient says mini stroke

Answer 53

Transient Ischemic Attack (TIA)

Question 54

Patient says blood clot in my leg

Answer 54

Deep Vein Thrombosis (DVT)

Question 55

Patient says bulge in my aorta

Answer 55

Aortic Aneurysm

Question 56

Patient says bad blood flow to my legs

Answer 56

Peripheral Vascular Disease (PVD)

Question 57

Patient says tonsils removed

Answer 57

Tonsillectomy

Question 58

Patient says adenoids removed

Answer 58

Adenoidectomy

Question 59

Patient says ear tubes

Answer 59

Pressure Equalizer (PE) tubes

Question 60

Patient says balloon in my heart

Answer 60

Angioplasty (PMHx of CAD)

Question 61

Patient says stents in my heart

Answer 61

Coronary stents (PMHx of CAD)

Question 62

Patient says heart bypass

Answer 62

Coronary Artery Bypass Graft (CABG) [PMHx of CAD]

Question 63

Patient says breast removal

Answer 63

Mastectomy

Question 64

Patient says part of my lung removed

Answer 64

Partial lobectomy

Question 65

Patient says appendix removed

Answer 65

Appendectomy

Question 66

Patient says gallbladder removed

Answer 66

Cholecystectomy

Question 67

Patient says part of my colon removed

Answer 67

Partial colectomy

Question 68

Patient says spleen removed

Answer 68

Splenectomy

Question 69

Patient says kidney removed

Answer 69

Nephrectomy

Question 70

Patient says uterus removed

Answer 70

Hysterectomy

Question 71

Patient says ovary removed

Answer 71

Oophorectomy

Question 72

Patient says ovary removed and fallopian tube removed

Answer 72

Salpingo-oophorectomy

Question 73

Patient says prostate removed

Answer 73

Prostatectomy

Question 74

Family History

Answer 74

Includes any medical condition present in the patient's blood relatives; age of onset less than 55 years old is important for genetic risk factors

Question 75

Social History

Answer 75

Tobacco Use/Vaping; Alcohol use; Drug use; Occupational circumstances; Living circumstances

Question 76

Tobacco Use/Vaping

Answer 76

Packs Per Day (PPD)

Question 77

Drug Use

Answer 77

What substance?; Route of administration; Date of last use/how often?

Question 78

Occupation

Answer 78

Manual labor; Stress; Night shifts; etc.

Question 79

Living Circumstances

Answer 79

Live alone; Live with family/friends; Nursing home/assisted living; Hospice; Homeless

Question 80

True allergy

Answer 80

Rash, itching, swelling, difficulty breathing