Medical scribe

CC (Chief Complaint)

Main reason the patient is visiting

HPI (History of Present Illness)

Detailed story of the patient's current problem or symptoms

PMH (Past Medical History)

Patient's previous or current medical conditions

PSH (Past Surgical History)

Patient's previous surgeries

FH (Family History)

Relevant medical conditions in the patient's family

SH (Social History)

Smoking

ROS (Review of Systems)

Questions about symptoms involving different body systems

PE (Physical Exam)

Findings from the physician's examination

Assessment

Physician's clinical impression or diagnosis

Plan

What the physician intends to do next

Dx (Diagnosis)

Identification of a disease or medical condition

Hx (History)

Past or current medical history

F/U (Follow-up)

A subsequent visit to monitor a patient's condition or treatment

RTC (Return to Clinic)

Instruction for when the patient should return

HTN (Hypertension)

High blood pressure

HLD (Hyperlipidemia)

High cholesterol or abnormal levels of fats in the blood

DM (Diabetes Mellitus)

A condition involving abnormally high blood sugar

T1DM (Type 1 Diabetes Mellitus)

Diabetes caused by the body's inability to produce sufficient insulin

T2DM (Type 2 Diabetes Mellitus)

Diabetes in which the body does not use insulin effectively and/or does not produce enough

A1C (Hemoglobin A1c)

Blood test that measures average blood sugar over approximately 2–3 months

Hyperglycemia

High blood sugar

Hypoglycemia

Low blood sugar

CAD (Coronary Artery Disease)

Disease involving narrowing or blockage of the arteries supplying the heart

CHF (Congestive Heart Failure)

Condition in which the heart cannot pump blood effectively enough to meet the body's needs

MI (Myocardial Infarction)

Heart attack

CVA (Cerebrovascular Accident)

Stroke

Edema

Swelling caused by excess fluid buildup in tissues

Nephrology

Medical specialty focused on the kidneys

Nephrologist

Doctor who specializes in kidney diseases

Renal

Relating to the kidneys

CKD (Chronic Kidney Disease)

Long-term damage or decreased function of the kidneys

AKI (Acute Kidney Injury)

Sudden decrease in kidney function

ESRD (End-Stage Renal Disease)

Severe kidney failure requiring dialysis or kidney transplantation

eGFR (Estimated Glomerular Filtration Rate)

Estimate of how well the kidneys are filtering blood

Creatinine

Waste product in the blood commonly used to assess kidney function

BUN (Blood Urea Nitrogen)

Blood measurement of urea nitrogen that can help assess kidney function

Proteinuria

Excess protein in the urine

Albuminuria

Excess albumin in the urine

Hematuria

Blood in the urine

Dysuria

Painful or uncomfortable urination

Polyuria

Excessive urination

Oliguria

Abnormally low urine output

Anuria

Little or no urine production

Uremia

Buildup of waste products in the blood due to severe kidney dysfunction

Dialysis

Treatment that removes waste and excess fluid when the kidneys cannot do so adequately

Hemodialysis

Dialysis in which blood is filtered through a machine

Peritoneal Dialysis

Dialysis that uses the lining of the abdomen to filter waste and excess fluid

SOB (Shortness of Breath)

Difficulty breathing or feeling unable to get enough air

DOE (Dyspnea on Exertion)

Shortness of breath during physical activity

CP (Chest Pain)

Pain or discomfort in the chest

Palpitations

Feeling of a racing

N/V (Nausea/Vomiting)

Feeling sick to the stomach and/or vomiting

N/V/D (Nausea/Vomiting/Diarrhea)

Nausea

HA (Headache)

Pain or discomfort in the head

Syncope

Fainting or temporary loss of consciousness

Fatigue

Feeling unusually tired or lacking energy

Anorexia

Loss of appetite

Constipation

Difficult or infrequent bowel movements

Diarrhea

Frequent loose or watery stools

Hemoptysis

Coughing up blood

CBC (Complete Blood Count)

Blood test measuring red blood cells

CMP (Comprehensive Metabolic Panel)

Blood test measuring glucose

BMP (Basic Metabolic Panel)

Blood test measuring glucose

Na (Sodium)

Electrolyte important for fluid balance and nerve and muscle function

K (Potassium)

Electrolyte important for heart

Cl (Chloride)

Electrolyte involved in fluid and acid-base balance

CO₂

Blood measurement primarily reflecting bicarbonate and acid-base status

Ca (Calcium)

Mineral important for bones

Mg (Magnesium)

Mineral important for muscle

Phos (Phosphorus)

Mineral important for bones

Hgb/Hb (Hemoglobin)

Protein in red blood cells that carries oxygen

Hct (Hematocrit)

Percentage of blood made up of red blood cells

WBC (White Blood Cells)

Blood cells involved in immune defense

RBC (Red Blood Cells)

Blood cells that carry oxygen

Plt (Platelets)

Blood components involved in clotting

UA (Urinalysis)

Test that examines urine for blood

TSH (Thyroid-Stimulating Hormone)

Hormone used to assess thyroid function

NAD (No Acute Distress)

Patient does not appear to be in immediate distress

A&O x3 (Alert and Oriented x3)

Patient is alert and oriented to person

HEENT

Head

CV (Cardiovascular)

Relating to the heart and blood vessels

Resp (Respiratory)

Relating to breathing and the lungs

GI (Gastrointestinal)

Relating to the digestive system

GU (Genitourinary)

Relating to the urinary and reproductive systems

MSK (Musculoskeletal)

Relating to muscles

Neuro (Neurological)

Relating to the nervous system

Extremities

Arms and legs

CTA (Clear to Auscultation)

No abnormal sounds heard when listening to the lungs with a stethoscope

RRR (Regular Rate and Rhythm)

Heartbeat has a regular rate and rhythm

NT (Nontender)

Area does not hurt when examined

TTP (Tender to Palpation)

Pain or tenderness when an area is pressed during examination

Bilateral

Affecting both sides of the body

Unilateral

Affecting one side of the body

Distal

Farther away from the center of the body or point of attachment

Proximal

Closer to the center of the body or point of attachment

PO (Per Os)

By mouth

IV (Intravenous)

Through a vein

IM (Intramuscular)

Into a muscle

SQ/SubQ (Subcutaneous)

Under the skin

BID

Twice daily