Medical Scribe Initial Exam Flashcards


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created 7 years ago by kelss_taylor
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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 Failiure

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

Cardiovascular

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 (pulse)

31

Deep Vein Thrombosis

DVT

32

Diagnosis

Dx

33

Electrocardiogram

ECG/EKG

34

Extraocular Movements Intact

EOMI

35

Alcohol

EtOH

36

Family History

FHx

37

Follow Up

F/U

38

Fracture

Fx

39

Gastroesophageal Reflux Disease

GERD

40

Gastrointestinal

GI

41

Gravida/Para/Abortion

G/P/Ab

42

Genitourinary

GU

43

Headache

HA

44

Head, Ears, Eyes, Nose, Throat

HEENT

45

Health Insurance Portability and Accountability Act

HIPAA

46

Hyperlipidemia

HLD

47

History of Present Illness

HPI

48

Hypertension (high blood pressure)

HTN

49

History

Hx

50

Hemoglobin and Hematocrit

H & H

51

Incision and Drainage

I&D

52

Insulin Dependent Diabetes Mellitus

IDDM

53

Intrauterine Pregnancy

IUP

54

Intravenous Drug Abuse

IVDA

55

Left Lower Extremity

LLE

56

Left Lower Quadrant

LLQ

57

Last Normal Menstrual Period

LNMP

58

Loss of Consciousness

LOC

59

Lumbar Spine

L-spine

60

Left Upper Extremity

LUE

61

Left Upper Quadrant

LUQ

62

Myocardial Infarction

MI

63

Not Applicable

N/A

64

No Acute Distress, No Acute Disease

NAD

65

Non-insulin Dependent Diabetes Mellitus

NIDDM

66

No Known Drug Allergies

NKDA

67

Normal

nl/nml

68

Non Steroidal Anti-Inflammatory Drug

NSAID

69

Normal Sinus Rhythm

NSR

70

Nausea/Vomiting/Diarrhea

N/V/D

71

Oxygen Saturation

O2 Sat

72

Obstetrics and gynecology

OB/GYN

73

Overdose

OD

74

Otitis Media (inner ear infection)

OM

75

Oropharynx

OP

76

Open Reduction and Internal Fixation

ORIF

77

Primary Care Physician/Primary Medical Doctor

PCP/PMD

78

Physical exam/Pulmonary Embolism

PE

79

Pupils are Equal, Round, and Reactive, to Light

PERRL

80

Per Os (by mouth)

PO

81

As Needed

prn

82

Patient

Pt

83

Prior to Arrival -or- Peritonsillar Abscess

PTA

84

Peripheral Vascular Disease

PVD

85

Every

q

86

Every Day

QD

87

At Every Bedtime

QHS

88

Four Times a Day

QID

89

Right Lower Extremity

RLE

90

Right Lower Quadrant

RLQ

91

Range of Motion

ROM

92

Review of System

ROS

93

Regular rate and rhythm (normal heart sounds)

RRR

94

Right Upper Extremity

RUE

95

Right Upper Quadrant

RUQ

96

Prescription

Rx

97

Rule Out

r/o

98

Shortness of Breath

SOB

99

Subjective, Objective, Assessment, and Plan

SOAP

100

Status Post (after)

s/p

101

Symptoms

Sx

102

S/T Elevation Myocardial Infarction

STEMI

103

Tonsillectomy and Adenoidectomy (tonsils and adenoids removal surgery)

T & A

104

Transient Ischemic Attack

TIA

105

Three Times a Day

TID

106

Tympanic Membrane (ear drum)

TM

107

Treatment

Tx

108

Thoracic Spine

T-spine

109

Urinalysis

UA

110

Upper Respiratory Infection

URI

111

Ultrasound

US

112

Up to Date

UTD

113

Urinary Tract Infection

UTI

114

Within Normal Limits (normal, not of concern)

WNL

115

Year(s) Old

y/o