ScribeAmerica Final

chief complaint

the main reason for the patient’s outpatient visit

EMR / EHR

electronic medical record / electronic health record

subjective

feeling

objective

factual finding from the provider

pain

patient’s feeling of discomfort

tenderness

doctor’s finding of reproductible plan

acute

new onset, likely concerning

chronic

long-standing, not of direct concern

new patient

a patient that has never been seen at the clinic, or was seen greater than 3 years ago

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no previous records, longer visit, detailed chart

established patient

a patient that has been seen at the clinic (by any provider) within the last 3 years

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previous records available, shorter visit, concise chart

diagnostic visit

type of visit:

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new problem

chief complaint: new symptom

goal is to determine the cause of the problem and appropriate treatment

health management

type of visit:

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check-up

chief complaint: routine physical or management of chronic problem(s)

goal is preventative care and/or assessing progress of ongoing medical problems

What is the medical chart abbreviation (includes what happens at the appointment)

SOAP

What are included in the “s” (subjective) portion of SOAP

History of Present Illness (HPI) and Review of Systems (ROS)

What is included in “Past History”

Medical, Surgical, Social, and Family history

What is included in the “o” (objective) portion of SOAP

Physical examination (PE) and Order & Results

What is the “a” portion of SOAP

Assessment

what is the “p” portion of SOAP

Plan

What is History of Present Illness (HPI)

The story and context of the Chief complaint

The patient complaint

What is the Reviews of Systems

a head to toe list of positive and negatives

the patient complaint

what is the Physical Examination (PE)

The physician’s objective findings

What is the Assessment

current diagnoses

what is the plan

treatment plan and follow up

layman’s term

what the patient will likely call the disease

medical term

what the scribe/provider will document

high blood pressure in medical terms

Hypertension (HTN)

high cholesterol in medical terms

hyperlipidemia (HLD)

Diabetes in medial terms

diabetes mellitus (DM)

type 2 diabetes in medical terms

non insulin dependent diabetes mellitus (NIDDM)

type 1 diabetes in medical terms

insulin dependent diabetes mellitus (IDDM)

heart disease in medical terms

Coronary Artery Disease (CAD)

heart attack in medical terms

Myocardial infarction (MI)

Heart failure in medical terms

Congestive heart failure (CHF)

Irregular heartbeat in medical terms

arrhythmia

Emphysema or Chronic Bronchitis in medical terms

Chronic obstructive pulmonary disease (COPD)

Blood clot in lung in medical terms

Pulmonary Embolism (PE)

Pneumonia or lung infection in medical terms

Pneumonia (PNA)

Reflux in medical terms

gastroesophageal reflux disease (GERD)

ulcers in medical terms

gastric ulcer or peptic ulcer disease (PUD)

irritable bowel in medical terms

irritable bowel syndrome (IBS)

bladder infection in medical terms

urinary tract infection (UTI)

kidney infection in medical terms

pyelonephritis

“i’m on dialysis” in medical terms

chronic kidney disease (CKD) on dialysis

enlarged prostate in medical terms

benign prostatic hypertrophy (BPH)

stroke in medical terms

cerebrovascular accident (CVA)

“blood clot in the brain” in medical terms

ischemic CVA

brain bleed in medical terms

hemorrhagic CVA

“mini stroke” in medical terms

transient ischemic attack (TIA)

blood clot in leg in medical terms

deep vein thrombosis (DVT)

bulge in aorta in medical terms

aortic aneurysm

“bad blood flow in my legs” in medical terms

peripheral vascular disease (PVD)

cancer in medical terms

cancer or carcinoma (CA)

spread to my…. in medical terms

with metastasis to the….

chemo in medical terms

chemotherapy

radiation in medical terms

radiation therapy

“they cut it out” in medical terms

status-post surgical resection

“it’s gone” in medical terms

in remission

what are symptoms of a true allergy

rash

itching

swelling

or difficulty breathing

what does PSx mean

past surgical history

Tonsils removed in medical terms

tonsillectomy

adenoids removed in medical terms

adenoidectomy

“neck arteries cleaned” in medical terms

carotid endarterctomy

Leg amputated in medical terms

Above knee amputation (AKA)

Below knee amputation (BKA)

joint repair in medical terms

arthroplasty

“ballon in my heart” in medical terms

angioplasty

what should be included in the PMHx of someone who had an angioplasty done

PMHx = coronary artery disease (CAD)

“stents in my heart” in medical terms

Coronary Stents

What should be included in the PMHx of someone who has coronary stents

PMHx = coronary artery disease (CAD)

Heart Bypass in medical terms

Coronary Artery Bypass Graft (CABG)

what should be included in the PMHX of someone who has a coronary artery bypass graft (CABG)

PMHx = coronary artery disease (CAD)

breast removal in medical terms

Mastectomy

part of the lung removed in medical terms

partial lobectomy

appendix removed in medical terms

appendectomy

gallbladder removed in medical terms

cholecystectomy

part of the colon removed in medical terms

partial colecetomy

spleen removed in medical terms

splenectomy

kidney removed in medical terms

nephrectomy

uterus removed in medical terms

hysterectomy

ovary removed in medical terms

oophorectomy

What at what age would a family member’s risk of disease be increased

under 55

what does FHx mean

family history

what is included in family history

any medical condition present in the patient’s blood relatives

what is SHx

social history

what is included in social history

alcohol use

tobacco use/vaping

drug use

occupation

living circumstances

chronic disease

an illness that lasts longer than 3 months

cause about 70% of deaths in the US

approx. 90% of seniors have a chronic illness, and over 75% have two or more

comorbidity

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

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ex: a patient has both HTN and HLD

why does comorbidity make a patient complex

1. the treatment of one disease may affect or contradict the treatment of the second
2. adverse drug interactions
3. compounding symptoms may lead to poor compliance with treatment plan
4. if both illnesses affect a specific organ system, the patient is at increased risk of organ failure

etiology (cause) of hypertension (HTN)

an increase in blood pressure causes excess force again the arterial walls, damaging arteries over time

risk factors of hypertension (HTN)

FHx of HTN

obesity

high sodium diet

smoking

ETOH (alcohol)

symptoms of hypertension (HTN)

often asymptomatic

headache is the most common symptom

diagnosis of hypertension (HTN)

diagnosed through blood pressure reading.

typically it takes several high readings to confirm HTN

systolic blood pressure

measures the pressure in the arteries when the heart contracts (beats)

diastolic blood pressure

measures the pressure in the arteries when relaxed (between the heart beats)

what numbers are considered hypotensive

sys: less than 90

dia: less than 60

what numbers are considered normal (blood pressure)

sys: 90 to 120

dia: 60 to 80

what numbers are considered prehypertensive

sys: 121 to 140

dia: 81 to 90

what numbers are considered hypertensive

sys: greater than 140

dia: greater than 90

what can hypertension lead to

impaired vision

cerebrovascular accident (CVA)

Coronary artery disease (CAD)

myocardial infarction (MI)

renal failure

Congestive Heart Failure (CHF)

non-pharmacological management of hypertension (HTN)

low sodium diet

stop smoking and ETOH (alcohol)

exercise

BP log at home

pharmacological management of hypertension (HTN)

ACE inhibitors

Ca Channel Blockers

Diuretics

ARBs