Basic/Common Scribe Vocab Flashcards
Chief complain
Main reason for the patient’s ED visit
EMR/EHR
Electronic Health Record
Subjective
Feeling
Objective
Factual finding from the provider
Pain
Patient’s feeling of discomfort
Tenderness
Doctor’s finding of reproducible pain
Acute
New onset, likely concerning
Chronic
Long0standing, not of direct concern
HR
Heart Rate (bpm)
BP
Blood Pressure (mmHg)
RR
Respiratory Rate
T
Temperature (C or F)
SaO2
Oxygen Saturation(%)
CC
Chief Complain
HPI
History of Present Illness
ROS
Review of Systems
PE
Physical Exam
DDx
Differential Diagnoses
Differential Diagnoses
Physician generated list of possible things causing patient’s subjective symptoms
MDM
Medical Decision Making
Disposition
Next steps or final step in medical care
HPI
History of Present Illness
Dx
Diagnosis
Hypertension (HTN)
High blood pressure
Hyperlipidemia (HLD)
High cholestorol
Diabetes Mellitus (DM)
Diabetes
“Only pills for my diabetes”
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
“Insulin shots for my diabetes”
Insulin Dependent Diabetes Mellitus (IDDM)