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Training Class 2
Scribe America terminology, abbreviations and chart information
66
Medical
Professional
01/30/2015
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Term
ED Flow
 Definition
Walk-in/EMS, Triage, Bed Placement, Nurse Assessment, H&P, Differential Dx, Physician Orders, Progress Notes, Final Dx, Disposition
Term
Vital Signs
 Definition
HR, BP, RR, T, SaO2
Term
HPI
 Definition
History of Present Illness: the story and context of the chief complaint, SUBJECTIVE
Term
ROS
 Definition
Review of Systems: a head-to-toe list of positives and negatives, SUBJECTIVE
Term
PMHx
 Definition
past medical history
Term
PSHx
 Definition
past surgical history
Term
FHx
 Definition
family history
Term
SHx
 Definition
social history
Term
PE
 Definition
Physical Examination: the physician's objective findings, OBJECTIVE
Term
Progress Notes
 Definition
Objective results (Labs, XR), re-evals, consults, OBJECTIVE
Term
Disposition
 Definition
Admitted or discharged?
Term
hyperlipidemia
 Definition
high cholesterol
Term
atrial fibrillation
 Definition
A-Fib, "irregular heartbeat"
Term
supraventricular tachycardia
 Definition
SVT, palpitations
Term
GERD
 Definition
gastroesophageal reflux disease
Term
pyelonephritis
 Definition
pyelo, kidney infection
Term
renal calculi
 Definition
kidney stones
Term
CRF
 Definition
chronic renal failure, "on dialysis"
Term
benign prostate hypertrophy
 Definition
BPH, enlarged prostate
Term
SZ
 Definition
seizure disorder/epilepsy
Term
Hemorrhagic CVA
 Definition
"brain bleed"
Term
alcoholism
 Definition
EtOH abuse
Term
PVD
 Definition
peripheral vascular disease, "bad blood flow to the legs"
Term
DDD
 Definition
degenerative disc disease, "bulging/herniated disc"
Term
OA/RA
 Definition
osteoarthritis/rheumatoid arthritis
Term
DJD
 Definition
degenerative joint disease = OA
Term
tonsils removed
 Definition
tonsillectomy
Term
adenoids removed
 Definition
adenoidectomy
Term
ear tubes
 Definition
pressure equalizer (PE) tubes
Term
"Surgery for Afib"
 Definition
Afib s/p cardiac ablation
Term
breast removal
 Definition
mastectomy
Term
hole in neck
 Definition
tracheostomy, "trach"
Term
part of lung removed
 Definition
partial lobectomy
Term
appendix removed
 Definition
appendectomy
Term
gallbladder removed
 Definition
cholecystecomy
Term
hernia repair
 Definition
herniorrhaphy
Term
part of colon removed
 Definition
partial colectomy
Term
bag to collect stool
 Definition
colostomy
Term
spleen removed
 Definition
splenectomy
Term
"stomach stapled"
 Definition
gastric bypass
Term
uterus removed
 Definition
hysterectomy
Term
ovary removed
 Definition
oophorectomy
Term
ovary and fallopian tubes removed
 Definition
salpingo-oophorectomy
Term
"tubes tied"
 Definition
tubal ligation (female), vasectomy (male)
Term
C-section
 Definition
Cesarean section
Term
prostate removed
 Definition
prostatectomy, trans-urethral removal of the prostate (TURP)
Term
"neck artery cleaned"
 Definition
carotid endarterectomy
Term
brain surgery
 Definition
craniotomy
Term
shunt (brain)
 Definition
ventriculoperitoneal (VP) shunt
Term
dialysis fistula
 Definition
arteriovenous (AV) fistula
Term
dialysis graft
 Definition
AV graft
Term
PICC line
 Definition
peripherally inserted central catheter
Term
port
 Definition
port-a-cath or Medi-Port
Term
clot filter (lower abdomen)
 Definition
inferior vena cava (IVC) filter
Term
clot filter (leg)
 Definition
Greenfield Filter
Term
AKA
 Definition
above knee amputation
Term
BKA
 Definition
below knee amputation
Term
joint repair
 Definition
arthroplasty
Term
metal plates/pins
 Definition
hardware
Term
"neck fused"
 Definition
cervical spinal fusion
Term
"back fused"
 Definition
lumbar spinal fusion
Term
HR
 Definition
heart rate
Term
BP
 Definition
blood pressure
Term
RR
 Definition
respiratory rate
Term
T
 Definition
temperature
Term
SaO2
 Definition
oxygen saturation
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