CityMD Scribe Tech (MC Exam Practice)

Patient stated he took 2 tablets of tylenol for his knee pain, in which section should this be documented?

History of Present Illness

What POC tests can scribes perform?

rapid strep (&throat culture), rapid flu, rapid covid, COMBO test, urinalysis, urine culture, ucg pregnancy test, visual acuity

30 yr old female c/o dysuria for 3 days, what POC should we run?

Urinalysis, Urine Pregnancy

What type of panel does not require taking blood?

stool

What is a “2-code”?

service only, no symptoms

What is a “3-code”?

simple, low complexity case

What is a “4-code”?

case with moderate complexity

What is a “5-code”?

sent to ER

What does the 0 of an E&M code mean?

new patient

What does the 1 of an E&M code mean?

established patient

How do you calculate respiratory rate?

Count chest rises for 15 seconds, multiply by 4

black flag

pt workup needed

blue flag

scribe is in room

yellow flag

provider

green flag

provider

white flag

procedure being done on pt

red flag (half open)

next patient for provider

red flag (fully open)

second patient for provider

all flags up, door open

room needs cleaning

all flags up, door closed

private conversation, don’t enter

What is the only bucket scribes use on Athena?

orders/Rx/auths

When do we manually change patient status?

From “ready for provider” to “with provider”

What is the typical respiratory rate?

16

What is the typical respiratory rate for children?

20-22

How long does rapid strep test take?

5 mins

How long does rapid flu test take?

10 mins

How long does rapid covid test take?

15 mins

How long does BD combo test take?

15 mins

How long does a UGC-pregnancy test take?

3-5 mins

erythema

redness

ecchymosis

bruising

lymphadenopathy (LAD)

swollen lymph nodes

pyelonephritis

kidney infection

organomegaly

enlarged organs

hepatosplenomegaly

enlargement of spleen and liver

ROM

range of motion

crepitus

grating or popping sound

What is the only swab in the room?

e-swab

What do we include in. the note to the imaging facility?

PE findings, eval for…?

Where and how do you document x-ray results?

Physical Exam —> “XRAY WET READ” —> (Input X-ray results)…(Provider Initials)

What do we include in the note to the imaging facility?

(STAT) type of imaging study, with/without contrast, “WET READ REQUIRED”, PE findings, eval for…?

What information needs to be documented for every vaccine/therapeutic injection?

Lot #, Exp Date, Site (i.e Rt deltoid), Administered

PO

Orally by mouth

IV

intravenous

IM

intramuscular

SC

subcutaneous/ directly underneath the skin

ID

intradermal/ into the inner layer of skin

PR

per rectum

PV

per vagina

SL

sublingual/ beneath the tongue

Ophthalum

ophthalmic/ on the external eye

Otic

by way of ear

Nasal

by way of nose

Inhalational

Within the respiratory tract by inhaling orally or nasally

Topical

On the outer surface of the skin

QD

once a day

BID

twice a day

TID

three times a day

QID

four times a day

QW

Once a week

BIW

two times a week

TIW

three times a week

QHS

at bedtime

QAM

in the morning

QPM

at night

Q#H

Every # Hours

Q# - #

Every # - # hours

PRN

as needed

What is the goal time from start to HPI?

10 mins

What types of transmission do we take precautions for?

Contact, Droplet, Airborne

What are the transmission-based precautions for contact?

gloves, gown

What are the transmission-based precautions for droplet?

mask, gloves

What are the transmission-based precautions for airborne?

N95 mask, gloves

What items should be placed in the red biohazard bag?

anything saturated or caked with blood, used empty urine specimen cups, expired medication, rapid COVID casettes

What temperatures indicate a critical situation?

>103.5, <93

What pulse indicates a critical situation?

>130, <40

What BP indicates a critical situation?

Systolic >200/ Diastolic >115, Systolic <90

What respiratory rate indicates a critical situation?

>24, <8

What pulse ox indicates a critical situation?

<90

What pulse ox indicates respiratory distress?

<95

What is the venipuncture set-up?

3- go to drawer- alcohol pad, tourniquet, bandaid

2- phlebotomy cabinet- butterfly needle, vacutainer

1- counter top- 2×2 gauze

All items get placed on a chuck

What labs are always STAT?

D. Dimer (for blood clots), Troponin (for heart attack)

When you call in for a STAT, what information do you need from the courier?

name, confirmation number

What is the routine for individual specimen bags?

affix labels to specimens, lab requisition (place specimens and printed requisition into a clear lab bag), check off the appropriate temp type on the bag

What is the routine for STAT individual specimen bags?

affix labels to specimens, lab requisition (place specimens and printed requisition into a red lab bag), check off the appropriate temp type on the bag

What are consolidation bags?

individual specimen bags of same temp/specimen type are placed in barcoded bags

What temperature and specimen types require their own consolidation bag?

room temp, keep refridgerated, frozen specimen, COVID-19, monkeypox

What are VCM swabs?

Viral Culture Mediums

What do VCM swabs test for?

wide range of viruses including COVID-19, herpes, varicella, MMR

What sources can VCM swabs be collected from?

nasal, lesion, oral

What are E-Swabs used for?

to identify bacterial infections: throat cultures, wound cultures, genital cultures

What is the Aptima Multi-Test (orange) swab used for?

Used to test for BV, Trich, Yeast, Gonorrhea, Chlamydia

What source is the Aptima Multi-Test (orange) swab used for?

vaginal only

What do we order a Aptima Multi-Test (orange) swab as?

“Vaginosis Panel”

What is the Aptima Multi-Test (White) swab used for?

test for gonorrhea, chlamydia, trich

What source is the Aptima Multi-Test (white) swab used for?

eye, throat, rectum, male genitals

What is Roche Urine Tube used for?

gonorrhea, chlamydia, trich

What are urine cultures used for?

tests for bacterial infections in the urine

What is the order of draw for urine collections?

1. gray tube (Urine Cx)

2. uCG Urine Pregnancy Test

3. Urinalysis dipstick

What is the immunization procedure setup?

vaccine with box, alcohol prep pads, bandaid, gauze