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Medical Scribe > Basic/Common Scribe Vocab > Flashcards

Basic/Common Scribe Vocab Flashcards

(72 cards)

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1
Q

Chief complain

A

Main reason for the patient’s ED visit

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2
Q

EMR/EHR

A

Electronic Health Record

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3
Q

Subjective

A

Feeling

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4
Q

Objective

A

Factual finding from the provider

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5
Q

Pain

A

Patient’s feeling of discomfort

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6
Q

Tenderness

A

Doctor’s finding of reproducible pain

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7
Q

Acute

A

New onset, likely concerning

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8
Q

Chronic

A

Long0standing, not of direct concern

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9
Q

HR

A

Heart Rate (bpm)

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10
Q

BP

A

Blood Pressure (mmHg)

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11
Q

RR

A

Respiratory Rate

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12
Q

T

A

Temperature (C or F)

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13
Q

SaO2

A

Oxygen Saturation(%)

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14
Q

CC

A

Chief Complain

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15
Q

HPI

A

History of Present Illness

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16
Q

ROS

A

Review of Systems

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17
Q

PE

A

Physical Exam

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18
Q

DDx

A

Differential Diagnoses

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19
Q

Differential Diagnoses

A

Physician generated list of possible things causing patient’s subjective symptoms

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20
Q

MDM

A

Medical Decision Making

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21
Q

Disposition

A

Next steps or final step in medical care

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22
Q

HPI

A

History of Present Illness

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23
Q

Dx

A

Diagnosis

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24
Q

Hypertension (HTN)

A

High blood pressure

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25
Hyperlipidemia (HLD)
High cholestorol
26
Diabetes Mellitus (DM)
Diabetes
27
“Only pills for my diabetes”
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
28
“Insulin shots for my diabetes”
Insulin Dependent Diabetes Mellitus (IDDM)
29
Coronary Artery Disease (CAD)
Heart disease
30
Myocardial Infarction (MI) and CAD
Heart attack
31
Congestive Heart Failure (CHF)
Heart failure
32
Arrythmia
Irregular heartbeat
33
Asthma
Asthma
34
Chronic Obstructive Pulmonary Disease (COPD)
Emphysema or Chronic Bronchitis
35
Pulmonary Embolism (PE)
Blood clot in lung
36
Pneumonia (PNA)
Pneumonia
37
Gastroesophageal Reflux Disease (GERD)
Reflux
38
Gastric Ulcer or Peptic Ulcer Disease (PUD)
Ulcers
39
Hepatitis
Hepatitis
40
Irritable Bowel Syndrome (IBS)
Irritable bowel
41
Urinary Tract Infection (UTI)
Bladder infection
42
Pyelonephritis
Kidney infection
43
Renal Calculi
Kidney stones
44
Chronic Kidney Disease (CKD) on dialysis
“On dialysis”
45
Benign Prostatic Hyperplasia (BPH)
Enlarged prostate
46
G:P:A:
Gravida- total # of pregnancies Para- total pregnancies with viable births Abortus- total miscarriages or elected abortions
47
Cereal Vascular Accident (CVA)
Stroke
48
Ischemic CVA
Blockage in the brain
49
Hemorrhagic CVA
Brain bleed
50
Transient Ischemic Attack (TIA)
“Mini stroke”
51
Deep vein Thrombosis (DVT)
Blood clot in the leg
52
Aortic Aneurysm
Bulge in the aorta
53
Peripheral Vascular Disease (PVD)
Bad blood flow in the legs
54
PSHx
Past Surgical Histories
55
Tonsillectomy
Tonsils removed
56
Adenoidectomy
Adenoids removed
57
Pressure Equalizer (P.E.) Tubes
Ear tubes
58
Angioplasty
Balloon in the heart
59
Coronary Stents
Stents in my heart
60
Coronary artery Bypass Graft (CABG)
Heart bypass
61
Mastectomy
Breast removal
62
Partial lobectomy
Part of lung removed
63
Appendectomy
Removed appedix
64
Cholecystectomy
Removed gallbladder
65
Partial colectomy
Part of colon removed
66
Splenectomy
Removed spleen
67
Nephrectomy
Removed kidney
68
Hysterectomy
Removed uterus
69
Oophorectomy
Removed ovary
70
Salpingo-oophorectomy
Ovary and ovarian tube removed
71
Prostatectomy
Removed prostate
72
PPD
Pack per day

Medical Scribe (2 decks)

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