Scribe Pre Classroom Training

Abduction

Movement of a body part away from the midline

Adduction

Movement of a body part toward the midline

Anatomical Position

The erect position of the body with arms at the side and palms of the. hands facing forward.

Anterior (Ventral)

Nearer to the front

Bilateral

Paired structures having right and left members

Contralateral

Occurring on the opposite side of the body

Deep

Farther from the surface

Depressor

A muscle whose contraction pulls down the part of the body to which it is attached.

Distal

Farther from the trunk or site of attachment

Dorsal

Situated toward the back of the body; also back of hand and top of foot

Dorsiflexion

Backward flexion or bending (hand/foot)

Extension

The straightening of a body part

External

Situated outside; exterior (refers to wall of cavity or hollow form)

Evert

To turn outward

Flexion

Bending or angulation of a body part

Frontal (Coronal)

Vertical planes that pass through the body at right angles to the median plane; divide the body into anterior and posterior parts

Inferior

Nearer to the feet

Internal

Inside (refers to wall of cavity or hollow form)

Invert

To turn inward

Ipsilateral

Occurring on the same side of the body

Lateral

Farther from the median plane

Levator

A muscle whose contraction raises the part of the body to which it is attached.

Medial

Nearer to the median plane

Midline

Divides body into a right and left side

Palmar

palm or surface of hand

Plantar

Sole side of foot

Plantar Flexion

Foot movement when toes flex down (pointing your toes)

Posterior

Nearer to the back

Pronator

Medial rotation of the forearm and hand so that the palm faces posteriorly

Prone

Body lying face down (chest down and back up)

Proximal

Nearer to the trunk or site of attachment

Supine

Body lying face up (chest up and back down)

Superior

Nearer to the head

Transverse

Horizontal planes that pass through the body at right angles to long axis; divides body into upper (superior) and lower (inferior) parts.

Volar

Relating to the palm of the hand or the sole of the foot

Afebrile

without fever

Ambulation

to walk (with a cane/walker)

Aneurysm

An excessive localized enlargement of an artery caused by a weakening of the artery wall.

Antiemetic

medication used to relieve nausea and vomiting

Antipyretics

medication used to reduce fever

Arrhythmia

An abnormal heart rhythm (AKA cardiac dysrhythmia)

Artery

A blood vessel that carries oxygenated blood away from the heart.

Arthralgia

pain in a joint

Articulation

connection between bones

Atelectasis

partial or total collapse of the lungs

Avulsion

The action of pulling or tearing away

Axilla

Armpit

Benign

a tumor that is not dangerous and does not spread

Bruit

An abnormal murmur or sound heard through a stethoscope

Cardiomegaly

Abnormal enlargement of the heart

Cephalgia

A headache

Cerumen

Earwax

Debridement

removal of foreign matter or dead tissue from a wound

Dentition

the teeth in situ or in the dental arch

Diaphoresis

excessive sweating

Downcodes

A reduction of reimbursement for medical services when documentation is missing in a medical chart.

Dysmenorrhea

painful menstruation

Dyspareunia

painful intercourse

Dyspepsia

Indigestion

Dysphagia

difficulty swallowing

Dyspnea

difficulty breathing

Dysuria

painful urination

Edema

swelling of body tissues due to an excessive accumulation of fluid in connective tissue or a serous cavity

Edentulous

without teeth

Effusion

escape of fluid into a cavity

Emaciate

to become extremely thin or lean; wasting

Embolism

obstruction of a blood vessel by a clot of blood or foreign substance

Emesis

vomiting

Epistaxis

bleeding from the nose

Febrile

with fever

**Gait

manner of walking

Gingiva

Gums

Gravid

Pregnant

Hematemesis

vomiting of blood

Hematochezia

bright red bloody stools

Hematoma

swelling of blood which occurs in an organ or tissue resulting from ruptured blood vessels

Hematuria

blood in the urine

Hemoptysis

coughing up blood

Hemothorax

the accumulation of blood in the pleural cavity

Hypotension

persistently low arterial blood pressure

Incontinence

inability to control bowel movements or urine

Infarct Tissue

death resulting from failure of blood supply

Inguinal

pertaining to the groin region

Ischemia

An inadequate blood supply to an organ or part of the body

Joint

articulation or junction between two or more bones or cartilage

Keloid

scar formation consisting of dense tissue

Lacrimal

to do with tears

Lethargy

fatigue/exhaustion

Ligament

fibrous tissue, binding bones together

Lingual

belonging to the tongue

Lymphadenopathy

enlargement of a lymph node

Malaise

generalized feeling of discomfort or weakness

Malignant

a tumor that can invade/destroy local tissues and spread to other parts of the body

Malleolus

projections on either side of the ankle joint from the lower leg bones (tibia/fibula)

Melena

Black, tarry-like stool

Missed Ancillary

When a test or procedure is performed on a patient, but it is not documented in the medical chart to allow for generation of a bill.

Myalgia

muscular pain

Myocardial Infarction

heart attack

Nares

Nostrils

Neuralgia

sharp pain along the course of a nerve or several nerves