Vituity ED Scribe – Comprehensive Pre-Classroom Training Notes

  • ED Patient Flow

    • Arrival (ambulance/transfer/triage) → Triage (RN/PA/NP) → Provider exam & orders → Re-eval/results → Disposition (admit, transfer, discharge).

Section 2 – Medical Terms

Part 1 – Anatomical Terms

  • Basic Structures

    • Artery: vessel carrying oxygenated blood away.

    • Vein: carries de-oxygenated blood to heart (except pulmonary).

    • Articulation/Joint, Axilla, Conjunctiva, Cornea, Gingiva, Ligament, Nares, Os, Shaft, Sclera, Tympanic Membrane.

  • Body Regions

    • Lacrimal (tears), Lingual (tongue), Inguinal (groin), Sciatic (hip).

  • Movements

    • Ab/Adduction, Flexion/Extension, Dorsiflexion, Plantar Flexion (toes point ↓), Evert/Invert, Levator/Depressor.

  • Directional Terms

    • Anterior/Posterior, Superior/Inferior, Medial/Lateral, Proximal/Distal, Superficial/Deep, Ipsi/Contralateral, Dorsal/Palmar/Volar, Supine (face up), Prone (face down), Frontal/Transverse planes.

Part 2 – General Medical Terms (Patient Descriptors)

  • Afebrile/Febrile, Diaphoresis (sweating), Dyspnea, Dysuria, Emesis, Epistaxis, Gait, Hematemesis/Hematochezia/Hematuria/Hemoptysis, Incontinence, Malaise, Melena, Paresthesia, Photophobia, Poly-dipsia/uria, Pruritus, Purulent, Syncope, Tinnitus, Waxing & Waning.

Part 3 – General Diagnoses & Ops

  • Aneurysm, Arrhythmia, Atelectasis, Benign vs Malignant, Bruit, Cardiomegaly, Edema/Effusion, Embolism, Hematoma/Hemothorax, Hypotension, Infarct/Ischemia, Keloid, Lymphadenopathy, Myocardial Infarction, Pleurisy, Torsion.

  • Operations/Charting: Antiemetic, Antipyretic, Debridement, Down-coding, Missed Ancillary, Para (# viable births).

Part 4 – Physical Exam Templates

  • General Appearance: Cachectic, Morbidly Obese, Nontoxic, WDWN.

  • Head/Eyes: Atraumatic, EOMI, Fundi Sharp, Icterus, Nystagmus, Papilledema, PERRL, Sub-conjunctival Hemorrhage, Visual Acuity.

  • Ear/Nose/Mouth: Bulging/Erythematous/ Retracted TM, Hemotympanum, Septal Deviation/Hematoma, Poor Dentition, Trismus, Tongue Laceration.

  • Throat/Neck: Ant Cervical LAD, Carotid Bruit, JVD, Meningismus, Nuchal Rigidity, Peritonsillar Abscess, Trachea/Uvula midline.

  • Heart: Bradycardia <60/\min, Tachycardia >100/\min, Murmurs (Systolic/Diastolic), Gallops, Rubs.

  • Back: CVA Tenderness, Midline Tenderness, Straight-Leg Raise, Saddle Anesthesia.

  • Respiratory: Apnea, Accessory Muscle Use, Rales, Rhonchi, Stridor, Tachypnea, Wheezes, Intercostal Retractions.

  • Abdomen: Distension, Ascites, Gravid, Murphy’s, McBurney’s, Psoas, Rovsing’s, Grey-Turner’s, Cullen’s, Tympanitic.

  • Genital/Rectal: Adnexal/CMT, Cremasteric Reflex, Guaiac +/-, Inguinal Hernia, Melena, Paraphimosis, POC, Rectal Tone.

  • Extremities: Pitting Edema, Snuff-box TTP, Homan’s, Valgus/Varus, Lachman’s, McMurray’s, Pain OOP, AKA/BKA.

  • Neuro: GCS, Grip Strength, Babinski, Pronator Drift, Romberg, Ataxic Gait, Dysarthria, Dysmetria.

  • Psych: Affect, Orientation (A/O\times4), SI/HI, Hallucinations.

  • Skin: Cyanosis, Ecchymosis/Contusion, Erythema, Fluctuance, Induration, Laceration, Maculopapular, Petechiae, Purpura, Urticaria, Wheal.

Section 3 – Medical Conditions

Part 1 – Cardio & Pulm Core

  • Cardio: ACS, Angina, Atherosclerosis, A-Fib, CAD, CHF, Hyperlipidemia/-cholesterolemia, HTN, STEMI/NSTEMI, SVT, VT, Unstable Angina.

  • Respiratory: Asthma, Bronchitis, COPD, Influenza, URI, Pneumonia (tx ⇒ antibiotics), Pleural Effusion, PTX, HTX, Empyema, PE (often from DVT), DVT definition.

Part 2 – GI & Neuro

  • GI: Appendicitis, Ascites, Biliary Colic, Chole-lithiasis/cystitis/docholithiasis, Cirrhosis, Diverticulosis/-itis, Gastritis, Gastroenteritis, GERD, GI Bleed, Hemorrhoids, Pancreatitis, SBO.

  • Neuro: Bell’s Palsy, Seizure vs Pseudo-seizure, CVA (Ischemic/Hemorrhagic), TIA (<24 h), SAH, Encephalitis, Meningitis.

Part 3 – Common Surgeries

  • Appendectomy, CABG, Cholecystectomy, Colectomy, Colostomy, Herniorrhaphy, Hysterectomy, Mastectomy, Nephrectomy, Salpingo-Oophorectomy, Thoracostomy (chest tube), Thoracotomy, Tonsillectomy, Tubal Ligation, TURP.

Section 4 – Medical Abbreviations

Anatomical

  • RLQ, LLQ, RUQ, LUQ, RUE/LUE, RLE/LLE, C1–C7, CN II–XII, HEENT, PTX, AP, etc.

Procedures/Tests

  • ABG, CBC, CXR, UA, CT, MRI, EKG, GCS, I\&D, FROM, NSR, PERRL, SBP/DBP, VS, TPA, etc.

Common, Condition & Timeline Abbrev

  • NPO, CSF, ETOH, PMD, PO, DC, DKA, GERD, PE, SBO, UTI, URI, Rx, BID/TID/QD/QH dosing, LMP, G_P_A_.

Section 5 – Optional Expanded Terminology (Quick Hit)

  • Skin: Abscess, Cellulitis, Psoriasis, Melanoma.

  • HEENT: Conjunctivitis, Otitis Media/Externa, Labyrinthitis, Peritonsillar Abscess.

  • Endocrine/Metabolic: DMI/DMII, DKA, Hypo/Hyper-natremia/kalemia/calcemia, Hypothyroid.

  • GU: Pyelonephritis, Nephrolithiasis, Testicular Torsion, BPH, Urinary Retention/Incontinence.

  • OB/GYN: Ectopic Pregnancy, Endometriosis, PID, Hyperemesis Gravidarum.

  • HEME/ONC: Anemia, Leukemia, Lymphoma, Neutropenia, Sickle Cell, Thrombocytopenia.

  • Infectious: C. Diff, HSV, HIV, TB, RSV, Herpes Zoster.

  • MSK: Fracture types (Displaced/Comminuted), Osteoarthritis, RA, Rhabdo, Sciatica, Plantar Fasciitis.

  • Psych & Tox: Bipolar, Schizophrenia, SI/HI, Acetaminophen or Salicylate Toxicity.

Medications Cheat-Sheet

  • Analgesics/Opioids: Morphine, Fentanyl, Dilaudid, Norco, Oxycontin, Percocet, Methadone.

  • Non-Opioid Pain/Anti-Inflammatory: Acetaminophen, Ibuprofen, Toradol, Prednisone, Solumedrol, Decadron.

  • Cardiac: Atenolol, Metoprolol, Lisinopril, HCTZ, Lasix, Nitroglycerin, Digoxin, Dopamine, Epinephrine, Atropine.

  • Antiarrhythmics: Adenosine, Diltiazem, Lidocaine, Amiodarone (implicit).

  • Antibiotics: Amoxicillin, Augmentin, Azithro, Bactrim, Cipro, Clinda, Flagyl, Keflex, Levaquin, Rocephin, Zosyn.

  • Anticoagulants/Thrombolytics: Heparin, Coumadin, Plavix, TPA.

  • Psych/Neuro: Ativan, Versed, Haldol, Xanax, Dilantin, Keppra (implied), Propofol, Ketamine, Etomidate, Succinylcholine (paralytic).

  • Respiratory: Albuterol, CPAP (device), Solumedrol, Epinephrine (anaphylaxis).

  • GI/Antiemetic: Zofran, Phenergan, Compazine.

Knowledge Check Answer Nuggets (for self-study)

  • Plantar Flexion + Supine; Hema- terms (uria, ptysis, temesis, tochezia); Icterus, Hemotympanum, Cachectic, Sub-conj Heme; EKG HR 75 normal; Laceration vs Contusion vs Abrasion vs Pustule images; Pneumonia tx = Antibiotics; TIA timeframe 24 h; Abdominal quadrants order RUQ→LUQ→RLQ→LLQ; UA/US/ROS/RRR mappings; Fill-ins: NPO, CSF, ETOH, PMD, PO, DC; Body-system match SOB-lungs, UTI-GU, AMI-CV; Dosing: BID 2×/day, TID 3×/day, QD daily, QH hourly.

Exam & Practical Notes

  • Pre-Classroom Exam pass requirement: \ge 70\%.

  • Focus items marked with * expected on exam.

  • Study all K-Checks; answer key page 76.

Ethical & Practical Implications

  • HIPAA compliance extends to social media—direct termination risk.

  • Accurate documentation prevents down-codes & missed ancillary billing → financial & legal impact.

  • Scribes enhance patient-centered care by freeing provider attention; ethical imperative for better bedside time and reduced error.

Real-World Links / Integration

  • Meal-break law compliance mirrors physician duty-hour rules: know local regs to avoid labor disputes.

  • Physical-exam terms map directly to EMR templates; memorization speeds charting.

  • Abbreviation fluency prevents miscommunication (e.g., D/C vs DC vs Discontinue).

  • Understanding pathophysiology (e.g., DVT → PE; ACS continuum) sharpens differential and helps anticipate provider needs.