Medical Scribe Terms (Class 1)
Subjective - CORRECT ANSWER-feeling
Objective - CORRECT ANSWER-factual finding or discomfort
Pain - CORRECT ANSWER-patients feeling of discomfort (subjective)
Tenderness - CORRECT ANSWER-doctors finding of reproducible pain
(objective)
Acute - CORRECT ANSWER-New onset, likely concerning
Chronic - CORRECT ANSWER-Long-standing, not of direct concern
High Blood Pressure - CORRECT ANSWER-Hypertension (HTN)
High Cholesterol - CORRECT ANSWER-Hyperlipidemia (HLD)
Diabetes - CORRECT ANSWER-Diabetes Mellitus (DM)
"I only take pills for my diabetes" - CORRECT ANSWER-Non-Insulin Dependent
Diabetes Mellitus (NIDDM) (type 2 diabetes)
"I take shots (insulin) for my diabetes" - CORRECT ANSWER-Insulin Dependent
Diabetes Mellitus (IDDM) (type 1 diabetes)
Heart disease - CORRECT ANSWER-Coronary Artery Disease (CAD)
Heart Attack - CORRECT ANSWER-Myocardial Infarction (MI) and CAD
Heart failure - CORRECT ANSWER-Congestive Heart Failure (CHF)
Irregular heartbeats - CORRECT ANSWER-arrhythmia
Asthma - CORRECT ANSWER-Asthma
, Emphysema or Chronic Bronchitis - CORRECT ANSWER-Chronic Obstructive
Pulmonary Disease (COPD)
Blood clot in lungs - CORRECT ANSWER-Pulmonary Embolism (PE)
Pneumonia - CORRECT ANSWER-Pneumonia (PNA)
Reflux - CORRECT ANSWER-Gastroesophageal Reflux Disease (GERD)
Ulcers - CORRECT ANSWER-Gastric Ulcer or Peptic Ulcer Disease (PUD)
pancreatitis - CORRECT ANSWER-pancreatitis
hepatitis - CORRECT ANSWER-hepatitis
Irritable bowel - CORRECT ANSWER-Irritable Bowel Syndrome (IBS)
Bladder Infection - CORRECT ANSWER-Urinary Tract Infection (UTI)
Kidney Infection - CORRECT ANSWER-Pyelonephritis
Kidney Stones - CORRECT ANSWER-renal calculi
"I'm on dialysis" - CORRECT ANSWER-Chronic Kidney Disease (CKD) on
dialysis
Enlarged Prostate - CORRECT ANSWER-Benign Prostatic Hyperplasia (BPH)
Stroke - CORRECT ANSWER-Cerebrovascular Accident (CVA)
Blockage in the brain - CORRECT ANSWER-Ischemic CVA
Brain Bleed - CORRECT ANSWER-Hemorrhagic CVA
"Mini Stroke" - CORRECT ANSWER-Transient Ischemic Attack (TIA)
Subjective - CORRECT ANSWER-feeling
Objective - CORRECT ANSWER-factual finding or discomfort
Pain - CORRECT ANSWER-patients feeling of discomfort (subjective)
Tenderness - CORRECT ANSWER-doctors finding of reproducible pain
(objective)
Acute - CORRECT ANSWER-New onset, likely concerning
Chronic - CORRECT ANSWER-Long-standing, not of direct concern
High Blood Pressure - CORRECT ANSWER-Hypertension (HTN)
High Cholesterol - CORRECT ANSWER-Hyperlipidemia (HLD)
Diabetes - CORRECT ANSWER-Diabetes Mellitus (DM)
"I only take pills for my diabetes" - CORRECT ANSWER-Non-Insulin Dependent
Diabetes Mellitus (NIDDM) (type 2 diabetes)
"I take shots (insulin) for my diabetes" - CORRECT ANSWER-Insulin Dependent
Diabetes Mellitus (IDDM) (type 1 diabetes)
Heart disease - CORRECT ANSWER-Coronary Artery Disease (CAD)
Heart Attack - CORRECT ANSWER-Myocardial Infarction (MI) and CAD
Heart failure - CORRECT ANSWER-Congestive Heart Failure (CHF)
Irregular heartbeats - CORRECT ANSWER-arrhythmia
Asthma - CORRECT ANSWER-Asthma
, Emphysema or Chronic Bronchitis - CORRECT ANSWER-Chronic Obstructive
Pulmonary Disease (COPD)
Blood clot in lungs - CORRECT ANSWER-Pulmonary Embolism (PE)
Pneumonia - CORRECT ANSWER-Pneumonia (PNA)
Reflux - CORRECT ANSWER-Gastroesophageal Reflux Disease (GERD)
Ulcers - CORRECT ANSWER-Gastric Ulcer or Peptic Ulcer Disease (PUD)
pancreatitis - CORRECT ANSWER-pancreatitis
hepatitis - CORRECT ANSWER-hepatitis
Irritable bowel - CORRECT ANSWER-Irritable Bowel Syndrome (IBS)
Bladder Infection - CORRECT ANSWER-Urinary Tract Infection (UTI)
Kidney Infection - CORRECT ANSWER-Pyelonephritis
Kidney Stones - CORRECT ANSWER-renal calculi
"I'm on dialysis" - CORRECT ANSWER-Chronic Kidney Disease (CKD) on
dialysis
Enlarged Prostate - CORRECT ANSWER-Benign Prostatic Hyperplasia (BPH)
Stroke - CORRECT ANSWER-Cerebrovascular Accident (CVA)
Blockage in the brain - CORRECT ANSWER-Ischemic CVA
Brain Bleed - CORRECT ANSWER-Hemorrhagic CVA
"Mini Stroke" - CORRECT ANSWER-Transient Ischemic Attack (TIA)
