ABT 253 Medical Scribe Flashcards


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created 2 years ago by lmbergin
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Medical Scribe
updated 2 years ago by lmbergin
Subjects:
medical assistants, medical scribes, medical office administration
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1

Abdomen/Abdominal

Abd

2

Antibiotics

Abx

3

Atrial Fibrillation

A fib

4

Acute Otitis Media (new ear infection)

AOM

5

Assessment and Plan

A/P

6

Acetylsalicylic Acid (aspirin)

ASA

7

Twice a Day

BID

8

Bilateral Lower Extremities

Bilat L E

9

Bowel Movement

BM

10

Blood Pressure

BP

11

With

c

12

Cancer, Carcinoma

CA

13

Coronary Artery Bypass Graft

CABG

14

Coronary Artery Disease

CAD

15

Complete Blood Count (bloodwork to look for infection or anemia)

CBC

16

Congestive Heart Failure

CHF

17

Chest Pain

CP

18

Complains of

c/o

19

Chronic Obstructive Pulmonary Disease

COPD

20

Chronic Renal Failure

CRF

21

Caesarean section

C-section

22

Cervical Spine

C-Spine

23

Computerized Assisted Tomography

CAT or CT

24

Clear to Auscultation

CTA

25

Cariovascular

CV

26

Cerebrovascular Accident

CVA

27

Chest X-ray

CXR

28

Diabetes Mellitus

DM

29

Dyspnea on Exertion

DOE

30

Dorsalis Pedis/Posterior Tibialis

DP/PT

31

Deep Vein Thrombosis

DVT

32

Diagnosis

Dx

33

Electrocardiogram

ECG/EKG

34

Extraocular Movements Intact

EOMI

35

Family History

FHx

36

Fracture

Fx

37

Gastroesophageal Reflux Disease

GERD

38

Gastrointestinal

GI

39

Gravida/Para/Abortion

G/P/Ab

40

Genitourinary

GU

41

Headache

HA

42

Head, Ears, Eyes, Nose, Throat

HEENT

43

Health Insurance Portability and Accountability Act

HIPPA

44

Hyperlipidemia

HLD

45

History of Present Illness

HPI

46

Hypertension

HTN

47

History

Hx

48

Hemoglobin and hematocrit

H & H

49

Incision and Drainage

I & D

50

Insulin Dependent Diabetes Mellitus

IDDM

51

Intrauterine Pregnancy

IUP

52

Intravenous Drug Abuse

IVDA

53

Left Lower Extremity

LLE

54

Left Lower Quadrant

LLQ

55

Last Normal Menstrual Period

LNMP

56

Loss of Consciousness

LOC

57

Lumbar Spine

L-spine

58

Left Upper Extremity

LUE

59

Left Upper Quadrant

LUQ

60

Myocardial Infarction

MI

61

Not Applicable

N/A

62

No Acute Distress, No Acute Disease

NAD

63

Non-insulin Dependent Diabetes Mellitus

NIDDM

64

No Known Drug Allergies

NKDA

65

Normal

nl/nml

66

Non Steroidal Anti-Inflammatory Drug

NSAID

67

Normal Sinus Rhythm

NSR

68

Nausea/Vomiting/Diarrhea

N/V/D

69

Oxygen Saturation

O2 Sat

70

Obstetrics and gynecology

OB/GYN

71

Overdose

OD

72

Otitis Media (inner ear infection)

OM

73

Oropharynx

OP

74

Open Reduction and Internal Fixation

ORIF

75

Primary Care Physician/Primary Medical Doctor

PCP/PMD

76

Physical exam/Pulmonary Embolism

PE

77

Pupils are Equal, Round, and Reactive, to Light

PERRL

78

Per Os (by mouth)

PO

79

As Needed

PRN

80

Patient

Pt

81

Peripheral Vascular Disease

PVD

82

Prior to Arrival -or- Peritonsillar Abscess

PTA

83

Every Day

QD

84

At Every Bedtime

QHS

85

Four Times a Day

QID

86

Right Lower Extremity

RLE

87

Right Lower Quadrant

RLQ

88

Range of Motion

ROM

89

Review of System

ROS

90

Regular rate and rhythm (normal heart sounds)

RRR

91

Right Upper Extremity

RUE

92

Right Upper Quadrant

RUQ

93

Prescription

Rx

94

Rule Out

r/o

95

Shortness of Breath

SOB

96

Subjective, Objective, Assessment, and Plan

SOAP

97

Status Post (after)

s/p

98

Symptoms

Sx

99

S/T Elevation Myocardial Infarction

STEMI

100

Tonsillectomy and Adenoidectomy (tonsils and adenoids removal surgery)

T & A

101

Transient Ischemic Attack

TIA

102

Three Times a Day

TID

103

Tympanic Membrane (ear drum)

TM

104

Treatment

Tx

105

Thoracic Spine

T-spine

106

Urinalysis

UA

107

Upper Respiratory Infection

URI

108

Ultrasound

US

109

Up to Date

UTD

110

Urinary Tract Infection

UTI

111

Within Normal Limits (normal, not of concern)

WNL

112

Year(s) Old

y/o