Intro to Medical Scribing

Normal Heart Rate (Adults)

60-100 bpm

Tachycardic (Adults)

>100 bpm

Bradycardic (Adults)

Normal Heart Rate (Infants)

120-160 bpm

Tachycardic (Infants)

>160 bpm

Bradycardic (Infants)

Normal Respiratory Rate (Adults)

12-20 breaths per minute

Tachypneic (Adults)

>20 breaths per minute

Bradypnea (Adults)

Normal Respiratory Rate (Infants)

30-50 breaths per minute

Tachypneic (Infants)

>50 breaths per min

Bradypnea (Infants)

Normal Blood Pressure (Adults)

120/80

Hypertensive (Adults)

>140/90

Hypotensive (Adults)

Normal Blood Pressure (Infants)

50-120 (only measures systolic pressure)

Normal Body Temperature

98.6-100.4 "afebrile"

Febrile

>100.4

Hypothermic

Oxygen Saturation

95%-100%

Hypoxic

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Only Type II Diabetics (95%)

Insulin Dependent Diabetes Mellitus (IDDM)

Can be either Type 1 or Type II Diabetics (5%)

Coronary Artery Disease (CAD)

Heart disease

Myocardial Infarction (MI)

Heart attack; death of the tissue

Congestive Heart Failure (CHF)

heart failure characterized by the heart cavity being unable to pump all the blood out of itself (congestive)

Arrhythmias

abnormal heart rhythms (Ex: Atrial Fibrillation)

Chronic Obstructive Pulmonary Disease (COPD)

Emphysema/Chronic Bronchitis; permanent lung damage

Pulmonary Embolism (PE)

Blood clot in lung

Gastroesophageal Reflux Disease (GERD)

Acid Reflux

IBS

Irritable Bowel Syndrome

CAD

If a patient has had a Myocardial infarction, Angioplasty, Coronary Stents, Coronary Artery Bypass Graft (CABG), that means they've also had ...

Cardiac catheterization

thin, flexible tube is guided into the heart via a vein or an artery to tells us what the arteries look like inside; diagnosis CAD

Pyelonephritis

Kidney infection

Renal calculi

Kidney stones

Chronic Kidney Disease

(CKD)

End Stage Renal Disease (ESRD)

"I'm on dialysis"

Benign Prostatic Hypertrophy (BPH)

Enlarged prostate

GPA

Gravida/Para/Abortus

Gravida (G)

Total number of pregnancies (all pregnancies, no matter the outcome!)

Para (P)

Number of pregnancies that resulted in viable births. (Twins: para of one!)

Abortus (A)

Total number of miscarriages or elective abortions.

Hemorrhagic Cerebrovascular Accident (HCVA)

Brain bleed

Ischemic Cerebrovascular Accident (ICVA)

Brain blockage or clot

Transient Ischemic Attack (TIA)

Mini-stroke

Stroke

Creates permanent brain damage

Ischemic

lack of blood flow, lack of oxygen

Transient

temporary; doesn't create permanent brain damage

Lower Extremity Deep Vein Thrombosis (DVT)

Blood clot in my leg

Aortic Aneurysm

"Bulge in my aorta"

\-most common: abdominal aortic aneurysm (AAA)

Peripheral Vascular Disease (PVD)

"Bad blood flow to my legs"

Peripheral Neuropathy

"Numbness in my legs"

PE

If the patient's blood clot in the leg traveled up the venous system, to the lungs, what other serious condition could result?

Osteoarthritis (OA) or Rheumatoid Arthritis (RA)

arthritis

Osteoporosis

Weak/fragile bones

Osteoarthritis (OA)

arthritis caused by loss of cartilage cushion covering bones in joint; most common in bearing weight joints; results in bone rubbing against bone

Rheumatoid Arthritis (RA)

rare autoimmune disease causing progressive destructive changes and inflammation in multiple joints, especially in the hands and feet

Tonsillectomy

Tonsils removed

Adenoidectomy

Adenoids removed

Cardiac catheterization

Heart cath (diagnoses CAD)

Angioplasty

Balloon; fixing the vessel, opening it back up.

(PMHx: CAD)

Coronary Stents

Stents; reinforces artery walls by putting a mesh (stent) device to hold the arter open

(PMHx: CAD)

Coronary Artery Bypass Graft (CABG)

Heart bypass; taking a vein and grafting it around the section that is damaged, making an alternative pathway for blood to travel/detour (PMHx CAD)

Mastectomy

Breast removal

Tracheostomy ("trach")

Hole in my neck

Partial lobectomy

Part of my lung removed

Appendectomy

Appendix removed

Cholecystectomy

Gallbladder removed

Herniorrhaphy

Hernia repair

Partial colectomy

Part of my colon removed

Colostomy

Bag to collect stool

Splenectomy

Spleen removed

Nephrectomy

Kidney removed

Hysterectomy

Uterus removed

Oophorectomy

Ovary removed

Salpingo-oophorectomy

Ovary & Fallopian tubes removed

Tubal ligation (female) or Vasectomy (male)

Tubes tied

Cesarean Section

C-Section; considered a major surgery

Prostatectomy

Prostate removed (Most often Transurethral Resection of the Prostate or TURP)

Dilation and Curettage (D&C)

Uterine product removed

Carotid Endarterectomy

Neck artery cleaned

Cerebral Shunt

- drains excess CSF

- relieves cranial pressure

Craniotomy

Brain surgery

AV (Arteriovenous) Fistula

Dialysis fistula

AV (Arteriovenous) Graft

Dialysis graft

Peripherally Inserted Central Catheter (PICC)

PICC Line

Port-a-cath or Medi-Port

Port

IVC (Inferior Vena Cava) Filter

Clot filter (lower abdomen)

Above Knee Amputation (AKA) or

Below Knee Amputation (BKA)

Leg amputated

Arthroplasty

Joint repair

Hardware

Metal plates/pins

End Stage Renal Disease

Q: Mr. Smith undergoes dialysis on M/W/F. What medical history does this indicate he suffers from?

Coronary artery disease

Q: If the patient states they have had a heart bypass, what should you document in their PMHx?

Rash, Itching, Swelling, SOB

Signs of a true allergic reaction

Nausea, Vomiting, Abdominal pain, Diarrhea, Dizziness

Signs of an adverse reaction

Providers

A physician or specialist doctor. They have usually obtained a doctoral degree in medicine or the specialty they practice. They diagnose and treat the patient.

Advanced Practice Providers

People who studied and obtained a medical degree that allows them to see patients, sometimes under the supervision of a physician or sometimes on their own. Depends on the state laws.

Ex: Nurse practitioner or Physician assistant; both have degrees that allow them to see patients and prescribe medicine, and a physician reviews and signs their charts if needed.

Nurses or Medical assistants

Nurses are trained in assisting with medical care, procedures, administering medicine, and more. Medical Assistants are more common in Outpatient clinics, as they do not need to perform the full scope of tasks as nurses do. They require less training.

Scribe

Responsible for charting the patient's visit and making sure its accurate and represents the providers efforts and what the patient told us. The chart should make sense with what the patient came in with and their diagnosis.