Scribe America Final

chief complaint

main reason for a patient’s outpatient visit

EMR / EHR

electronic medical record / electronic health record

acute

new onset, likely concerning

chronic

long-standing for more than 3 months, not of direct concern

new patient

has never been seen at the clinic or was seen greater than 3 years ago, no previous records, longer visit, detailed chart

established patient

has been seen at the clinic within the last 3 years, previous records available, shorter visit, concise chart

diagnostic visit

new problem, chief complaint is a new symptom, goal is to determine the cause of the problem and appropriate treatment

health management visit

check up, chief complaint is a routine physical or management of chronic problem, goal is preventative care and/or assessing process of ongoing medical problems

check in → chief complaint → history → physical → orders → results → assessment and plan → check out

clinic flow

hypertension or HTN

high blood pressure or an increase in blood pressure that causes excess force against the arterial walls, damaging arteries over time

• risk factors include FHx of HTN, obesity, high sodium diet, smoking, ETOH

• damages blood vessels around the heart, eyes, and in brain which can lead to renal failure, impaired vision, CVA, CAD/MI, CHF

hyperlipidemia or HLD

high cholesterol or an elevated level of lipid in the blood that causes plaque build-up along arterial walls

• risk factors include FHx of HLD, obesity, high lipid diet, ETOH, physical inactivity

diabetes mellitus or DM

diabetes

non-insulin dependent diabetes mellitus or NIDDM

“i only take pills for my diabetes”

insulin dependent diabetes mellitus or IDDM

“i take shots (insulin) for my diabetes”

coronary artery disease or CAD

heart disease in which there is narrowing of the coronary arteries that limits blood supply to the heart muscle causes ischemia

• risk factors include HTN, HLD, DM, smoking, FHx < 55 y/o

myocardial infarction or MI

heart attack

congestive heart failure or CHF

heart failure

cerebrovascular accident or CVA

stroke

ischemic CVA

“brain clot in brain”

hemorrhagic CVA

brain bleed

true allergy symptoms

rash, itching, swelling, or difficulty breathing

angioplasty

“balloon in my heart”

coronary artery bypass graft or CABG

heart bypass

family history or FHx

includes any medical condition present in the patient’s blood relatives

• younger age of onset (under 55) means higher genetic risk

social history or SHx

includes alcohol use, tobacco use/vaping, drug use, occupation, and living circumstances

comorbidities

the simultaneous presence of two chronic diseases or conditions in a patient

• increases a patient’s complexity and health risk

lisinopril (zestril) and lotensin (benazepril)

relax arteries and block reabsorption of water by the kidneys for HTN

norvasc (amlodipine) and cardizem (diltiazem)

dilate the arteries and reduce the force of the heart’s contractions for HTN

hydrochlorothiazide (HCTZ)

reduce the volume of fluid in the blood vessels by urinating excess fluid for HTN

cozaar (losartan) and benicar (olmesartan)

dilate the arteries for HTM

type 1 DM

insulin insufficiency in which the pancreas is unable to produce insulin to move glucose from the blood into the cells

• ALWAYS treated with insulin

type 2 DM

insulin resistance, in which consistently high blood glucose levels cause cells to become resistant to insulin

• risk factors include FHx of DM, obesity, high carb diet, lack of exercise

• can be treated with diet changes, non-insulin meds, or insulin

humalog

rapid acting insulin that is injected immediately before or after meals for DM

lantus

long acting insulin that is injected once daily for DM

sliding scale

insulin dosage that is injected based on current glucose for DM

metformin

long acting oral med that is taken with meals for DM

glyburide

oral med taken with meals which induces pancreas to produce insulin for DM

atorvastatin (lipitor), rosuvastatin (crestor), and simvastatin (zocor)

medications used to treat HLD by inhibiting the production of cholesterol

acetylsalicylic acid (ASA)

aka Aspirin, antiplatelet drug that prevents clotting for CAD

nitroglycerin (NTG)

vasodilator for CAD

past history

comprehensive list of a patient’s entire history that includes medical, social, family, and surgical history

problem list

includes all problems a patient has been diagnosed with, both previous and current

• includes a status to show which problems are active and which are resolved