CityMD Scribe Written Exam

Transmission Methods

Contact, Droplet, Airborne

Sharps Container

Needles, Syringes, Glass Vials, Lancets, Vacutainers

Red Biohazard Bag

Anything caked with bodify fluids or expired medicine in non-glass vials

Note to imaging facility

ex: STAT CT head w/ (oral/IV) contrast, WET READ REQUIRED, PE: 3cm linear laceration to LTL, Eval for: Intracranial Bleed

Most important bucket for scribes

Orders/Rx/Auths

What goes on all specimen containers

Name, DOB

What goes on all action notes

Confirmation number, Rep Name

Examples of common labs that require venipuncture template

CBC, STD Panel, Abdominal Pain

AMA Form

refusing physical exam, refusing medical treatment, refusing to go to ER

Do all charts get billing codes?

No. ex: OCCMED

Vitals

BP, HR, Temp, RR, SpO2, height, weight, Pain scale