Scribe America Exam Prep
Study online at https://quizlet.com/_jp3rin
1. Clinic Flow 1. Check in and Chief Complaint (diagnostic vs. health management - vitals)
2. History and Physical (HPI, ROS, Past History, PE, DDx)
3. Orders and Results
4. Assessment and Plan
5. Check out
2. PMHx past medical history
3. Layman's Terms what pt likely calls disease
4. Medical Term what scribe/provider will document
5. HTN hypertension - high BP
6. HLD hyperlipidemia - high cholesterol
7. DM diabetes mellitus
8. NIDDM non-insulin dependent DM - only takes pills
9. IDDM insulin dependent DM - takes shots (insulin)
10. CAD coronary artery disease - heart disease -> can lead to MI
11. MI myocardial infarction + CAD -- heart attack
12. CHF congestive heart failure
13. Arrythmia irregular heart beat
14. COPD chronic obstructive pulmonary disease - emphysema or chronic bronchitis
, Scribe America Exam Prep
Study online at https://quizlet.com/_jp3rin
15. PE pulmonary embolism - blood clot in lung
16. PNA pneumonia or lung infection
17. GERD gastroesophageal refulx disease
18. PUD gastric ulcer or peptic ulcer disease
19. Pyelonephritis kidney infection
20. CKD chronic kidney disease - usually on dialysis
21. BPH benign prostatic hyperplasia - enlarged prostate
22. CVA cerebrovascular accident - stroke
23. Ischemic CVA blood clot in brain
24. Hemorrhagic brain bleed
CVA
25. TIA transient ischemic attack - mini stroke
26. DVT deep vein thrombosis - blood clot in leg
27. Aortic Aneurysm bulge in aorta
28. PVD peripheral vascular disease - bad blood flow to leg
29. CA carcinoma - cancer
30. Metastasis spread to
31. Status-Post Sur- cut it off
gical Resection
, Scribe America Exam Prep
Study online at https://quizlet.com/_jp3rin
32. True Allergy rash, itching, swelling, or difficulty breathing
33. PSHx past surgical history
34. Tonsillectomy tonsils removed
35. Adenoidectomy adenoids removed
36. Carotid En- neck arteries cleaned
darterectomy
37. AKA above knee leg amputation
38. BKA below knee leg amputation
39. Arthroplasty joint repair
40. Angioplasty balloon in heart - PMHx of CAD
41. Coronary Stents stents in the heart - PMHx of CAD
42. CABG coronary artery bypass graft - heart bypass - PMHx of CAD
43. Mastectomy breast removal
44. Partial Lobecto- part of lung removed
my
45. Cholecystectomy gallbladder removed
46. Partial Colecto- part of colon removed
my
47. Splenectomy spleen removed
48. Nephrectomy kidney removed
Study online at https://quizlet.com/_jp3rin
1. Clinic Flow 1. Check in and Chief Complaint (diagnostic vs. health management - vitals)
2. History and Physical (HPI, ROS, Past History, PE, DDx)
3. Orders and Results
4. Assessment and Plan
5. Check out
2. PMHx past medical history
3. Layman's Terms what pt likely calls disease
4. Medical Term what scribe/provider will document
5. HTN hypertension - high BP
6. HLD hyperlipidemia - high cholesterol
7. DM diabetes mellitus
8. NIDDM non-insulin dependent DM - only takes pills
9. IDDM insulin dependent DM - takes shots (insulin)
10. CAD coronary artery disease - heart disease -> can lead to MI
11. MI myocardial infarction + CAD -- heart attack
12. CHF congestive heart failure
13. Arrythmia irregular heart beat
14. COPD chronic obstructive pulmonary disease - emphysema or chronic bronchitis
, Scribe America Exam Prep
Study online at https://quizlet.com/_jp3rin
15. PE pulmonary embolism - blood clot in lung
16. PNA pneumonia or lung infection
17. GERD gastroesophageal refulx disease
18. PUD gastric ulcer or peptic ulcer disease
19. Pyelonephritis kidney infection
20. CKD chronic kidney disease - usually on dialysis
21. BPH benign prostatic hyperplasia - enlarged prostate
22. CVA cerebrovascular accident - stroke
23. Ischemic CVA blood clot in brain
24. Hemorrhagic brain bleed
CVA
25. TIA transient ischemic attack - mini stroke
26. DVT deep vein thrombosis - blood clot in leg
27. Aortic Aneurysm bulge in aorta
28. PVD peripheral vascular disease - bad blood flow to leg
29. CA carcinoma - cancer
30. Metastasis spread to
31. Status-Post Sur- cut it off
gical Resection
, Scribe America Exam Prep
Study online at https://quizlet.com/_jp3rin
32. True Allergy rash, itching, swelling, or difficulty breathing
33. PSHx past surgical history
34. Tonsillectomy tonsils removed
35. Adenoidectomy adenoids removed
36. Carotid En- neck arteries cleaned
darterectomy
37. AKA above knee leg amputation
38. BKA below knee leg amputation
39. Arthroplasty joint repair
40. Angioplasty balloon in heart - PMHx of CAD
41. Coronary Stents stents in the heart - PMHx of CAD
42. CABG coronary artery bypass graft - heart bypass - PMHx of CAD
43. Mastectomy breast removal
44. Partial Lobecto- part of lung removed
my
45. Cholecystectomy gallbladder removed
46. Partial Colecto- part of colon removed
my
47. Splenectomy spleen removed
48. Nephrectomy kidney removed
