Scribe Training and Medical Terminology Review

Comprehensive flashcards covering medical vocabulary, anatomical terms, charting abbreviations, and scribe duties based on the lecture notes.

Scribe Role

A clinician's personal assistant whose primary responsibility is to lessen the burden of documentation and organization, improving efficiency and focus on patient care.

Required Typing Speed

A minimum of $50\,wpm$ is required.

Clinician Shift Length

Shifts can range from $8-12$ hours in length.

Anatomical Position

To stand erect with arms at the sides and palms of the hands turned forward.

Anterior

Situated in front of or directed toward the front.

C-spine

Cervical spine ($C1-C7$).

Diffuse

Generalized; not localized to any specific location.

Distal

Farther from the trunk of the body.

Epigastric

Upper central region of the abdomen.

Fontanel

Anatomical feature of an infant’s skull, the “soft-spot”.

Inferior

Lower on the body, farther from the head.

L-spine

Lumbar spine ($L1-L5$).

Lateral

Farther from the midline.

Medial

Nearer to the midline.

Prone

Body position lying face down with forearms and hands turned palm side down.

Proximal

Nearer to the trunk of the body.

Supine

Body position lying face up.

Suprapubic

Lower central region on the abdomen.

T-spine

Thoracic spine ($T1-T12$).

Acute

New onset, likely concerning; opposite of chronic.

Chronic

Long-standing, constant; opposite of acute.

Fluctuating

Symptoms that are always present but changing in severity, never fully resolving.

Intermittent

Symptoms that completely resolve at times, but continue to return repeatedly.

Paroxysmal

Occasional, sporadic, transient.

Transient

Resolving spontaneously after onset.

Family History (FHx)

Part of the medical chart listing family diseases that may put the patient at an increased risk.

Health Insurance Portability and Accountability Act (HIPAA)

Federal law providing national standards to protect sensitive patient health information from disclosure without consent.

History of present illness (HPI)

The part of the medical chart describing the development of the illness.

Review of system (ROS)

A checklist of symptoms the patient has or does not have, grouped by body system.

Status Post (s/p)

Meaning after; example: Headache s/p fall.

Within Normal Limits (WNL)

Normal, not of concern.

Abscess

A collection of pus beneath the skin.

Atrial fibrillation (A fib)

Irregular and often very rapid heart rhythm (arrhythmia).

Bell’s Palsy

A localized facial nerve dysfunction that causes facial droop and numbness.

Cerebrovascular accident (CVA)

Stroke; blood supply to the brain is restricted or absent due to hemorrhage or occlusion of a vessel.

Cholecystitis

Inflammation of the gallbladder.

Cholelithiasis

Production of gallstones.

Chronic obstructive pulmonary disease (COPD)

Chronic inflammatory lung disease that causes obstructed airflow from the lungs.

Congestive heart failure (CHF)

Serious condition in which the heart doesn't pump blood as efficiently as it should.

Coronary artery disease (CAD)

Buildup of plaque in the arteries that supply oxygen-rich blood to the heart.

Deep venous thrombosis (DVT)

Blood clot forms in a vein located deep inside the body, typically in the leg.

Ectopic pregnancy

Egg developing outside the uterus; extremely dangerous due to risk of rupture.

Gastroesophageal reflux disease (GERD)

Digestive disorder occurring when acidic stomach juices, food, or fluids back up into the esophagus.

Hypertension (HTN)

High blood pressure, typically $>140/90$.

Hypotension

Low blood pressure, typically $<100/65$.

Myocardial infarction (MI)

Death of cardiac muscle due to prolonged ischemia; a heart attack.

Pneumothorax

Presence of air or gas in the pleural space; collapsed lung.

Pulmonary Embolism

Blockage of the pulmonary artery due to a translocated clot.

Transient ischemic attack (TIA)

Transient “mini-stroke” where neurological function is regained completely with time.

Complete blood count (CBC)

Blood test used to evaluate overall health and detect disorders including anemia, infection, and leukemia.

Hemoglobin and Hematocrit (H&H)

Red blood cell measurements used to evaluate anemia.

BID

Twice Daily.

QID

Four Times a Day.

TID

Three Times a Day.

Cachectic

Extremely skinny, bony, malnourished.

Febrile

Elevated body temperature, fever, indicative of infection.

Lethargic

Septic, very sick, about to die.

Somnolent

Appearing drowsy.

Pupils are Equal, Round, and Reactive, to Light (PERRL)

Common normal eye exam finding.

Scleral icterus

Yellowing of the sclera (whites of the eye) due to jaundice.

Epistaxis

Nose bleed.

Pharyngeal erythema

Redness of the pharynx, indicating a throat infection.

Tinnitus

Ringing in the ears without external stimuli.

Tympanic membrane (TM)

The clear membrane inside the ear; the ear drum.

Jugular vein distention (JVD)

A sign of heart dysfunction appearing as distention in the neck.

Bradycardia

Slow heart rate ($HR < 60$).

Tachycardia

Fast heart rate ($HR > 100\,bpm$).

Normal sinus rhythm (NSR)

The rhythm of a healthy heart.

Regular rate and rhythm (RRR)

Normal heart sounds with a regular rate ($60-100\,bpm$).

Dyspnea

Difficulty/labored breathing, shortness of breath.

Rales

Wet crackling heard in the lungs, typically due to pneumonia or CHF.

Stridor

Upper airway noise; common sign in croup.

Hematemesis

Gross amounts of blood in the vomit.

Hematochezia

Bright red blood in the stool.

McBurney’s point

RLQ point tenderness indicative of appendicitis.

Murphy’s sign

Pain with palpation of the RUQ during a deep breath, indicative of cholecystitis.

Melena

Black tarry stool indicative of an upper GI bleed.

Gravida / Para / Abortion (G / P / Ab)

Number of times pregnant / number of live children born / number of failed pregnancies.

CVA tenderness

Costovertebral Angle tenderness; tenderness over the kidneys.

Malleolus

Bony prominence on each side of the ankle (medial and lateral).

Cyanosis

Blue color of the skin due to lack of oxygen.

Diaphoresis

Sweating.

Incision and drainage (I&D)

Procedure used to drain an abscess to relieve pain and speed healing.

Petechial rash

Red or purple discolorations that do not blanch, indicative of meningitis.

Turgor

Skin elasticity; poor turgor is a sign of dehydration or age.

Aphasic

Absence of the ability to neurologically generate or understand language.

Paresthesia

Abnormal tactile sensation often described as tingling, numbness, or pinpricking.

Postictal

State of somnolence and decreased responsiveness after a seizure.

-ectomy

Suffix meaning surgical removal.

-itis

Suffix meaning inflammation.

-scopy

Suffix meaning viewing with a scope.

Differential Diagnosis

The diseases that a physician is considering as the reason for the patient’s symptoms.