Medical Scribe (Scribe101)
vital signs - answer a series of measures that give an overview of a patient's overall
health; heart rate, respiratory rate, blood pressure, body temperature, oxygen saturation
heart rate - answer the rate that your heart is pumping blood (beats per minute) (normal:
60-100 bpm)
respiratory rate - answer rate of someone's breathing (breaths per minute) (normal: 12-
20 breaths per minute)
blood pressure - answer the pressure at which blood is being pumped throughout your
body (normal 90/60-140/90) (systolic over diastolic)
body temperature - answer measure of your body's ability to make and get rid of heat
(normal: 98.6-100.4)
oxygen saturation - answer the saturation of oxygen in your blood (normal: 95-100%)
tachycardic - answer fast heart rate, above 100 bpm
bradycardic - answers low heart rate, below 60 bpm
tachypneic - answerfast respiratory rate, above 20 breaths per minute
bradypnea - answerslow respiratory rate, below 12 breaths per minute
hypertensive - answerhigh blood pressure (>140/90)
hypotensive - answerlow blood pressure (<90/60)
afebrile - answerno fever
febrile - answerhigh body temperature, fever (>98.6)
hypothermic - answerlow body temperature (<98.6)
hypoxic - answerlow oxygen saturation (<95%)
emergency care - answerlife threatening conditions that require hospitalization
urgent care - answerillness or injury that does not appear to be life threatening but can't
wait until the next day
,in-patient care - answercare of patients whose condition requires admission to a
hospital
out-patient care - answermedical procedures, tests, and services that can be provided
to the patient in a setting that doesn't involve an overnight hospital stay
provider - answerThey have usually obtained a doctoral degree in medicine or the
specialty they practice. They diagnose and treat the patient. (physician or specialist
doctor)
advanced practice providers - answerPeople who studied and obtained a medical
degree that allows them to see patients, sometimes under the supervision of a
physician or sometimes on their own (nurse practitioner, P.A.)
nurses or medical assistants - answerNurses are trained in assisting with medical care,
procedures, administering medicine, and more. Medical Assistants are more common in
Outpatient clinics, as they do not need to perform the full scope of tasks as nurses do.
They require less training.
technicians - answerTrained in either certain equipment, specialties, or to assist with
patients! For example, a respiratory technician helps the ER with emergency cases,
coming in where patients can't breathe and require respiratory equipment.
medical scribe - answerResponsible for charting the patient's visit and making sure it's
accurate and represents the providers efforts and what the patient told us. The chart
should make sense with what the patient came in with and their diagnosis! While
scribes don't do patient care, we make sure that patient's are taken care of by us taking
care of the provider!
tachy - answerfast
brady - answerslow
hyper - answerabove
hypo - answerbelow
itis - answerinfection/inflammation
osis - answerdisease of
ectomy - answersurgical removal of
arthro - answerjoint
osteo - answerbone
, chole - answerbile
otomy - answerhole or opening
algia - answerpain
subjective - answerwhat the patient tells us, ex. pain
objective - answerwhat the provider and results tell us, ex. tenderness
medical history - answerany prior medical problems that include chronic medical
problems, past surgeries, allergies to medications
family history - answerdirect family members with a medical problem and includes all of
the same medical histories; always note age of family history to determine if genetic
social history - answerany history that occurs in daily life including alcohol use, smoking
or tobacco/nicotine, occupation, and living status
high blood pressure - answerHypertension (HTN)
high cholesterol - answerHyperlipidemia (HLD)
diabetes - answerDiabetes Mellitus (DM)
only pills for diabetes - answerNon-Insulin dependent diabetes Mellitus (NIDDM) (type
II)
insulin shots for diabetes - answerInsulin Dependent Diabetes Mellitus (IDDM) (type I or
type II)
cancer - answercancer or carcinoma (CA)
heart disease - answerCoronary Artery Disease (CAD)
heart attack - answerMyocardial Infarction (MI) and CAD
heart failure - answerCongestive Heart Failure (CHF)
abnormal rhythm - answerArrhythmias, ex. atrial fibrillation
asthma - answerasthma
Emphysema/Chronic Bronchitis - answerChronic Obstructive Pulmonary Disease
(COPD)
vital signs - answer a series of measures that give an overview of a patient's overall
health; heart rate, respiratory rate, blood pressure, body temperature, oxygen saturation
heart rate - answer the rate that your heart is pumping blood (beats per minute) (normal:
60-100 bpm)
respiratory rate - answer rate of someone's breathing (breaths per minute) (normal: 12-
20 breaths per minute)
blood pressure - answer the pressure at which blood is being pumped throughout your
body (normal 90/60-140/90) (systolic over diastolic)
body temperature - answer measure of your body's ability to make and get rid of heat
(normal: 98.6-100.4)
oxygen saturation - answer the saturation of oxygen in your blood (normal: 95-100%)
tachycardic - answer fast heart rate, above 100 bpm
bradycardic - answers low heart rate, below 60 bpm
tachypneic - answerfast respiratory rate, above 20 breaths per minute
bradypnea - answerslow respiratory rate, below 12 breaths per minute
hypertensive - answerhigh blood pressure (>140/90)
hypotensive - answerlow blood pressure (<90/60)
afebrile - answerno fever
febrile - answerhigh body temperature, fever (>98.6)
hypothermic - answerlow body temperature (<98.6)
hypoxic - answerlow oxygen saturation (<95%)
emergency care - answerlife threatening conditions that require hospitalization
urgent care - answerillness or injury that does not appear to be life threatening but can't
wait until the next day
,in-patient care - answercare of patients whose condition requires admission to a
hospital
out-patient care - answermedical procedures, tests, and services that can be provided
to the patient in a setting that doesn't involve an overnight hospital stay
provider - answerThey have usually obtained a doctoral degree in medicine or the
specialty they practice. They diagnose and treat the patient. (physician or specialist
doctor)
advanced practice providers - answerPeople who studied and obtained a medical
degree that allows them to see patients, sometimes under the supervision of a
physician or sometimes on their own (nurse practitioner, P.A.)
nurses or medical assistants - answerNurses are trained in assisting with medical care,
procedures, administering medicine, and more. Medical Assistants are more common in
Outpatient clinics, as they do not need to perform the full scope of tasks as nurses do.
They require less training.
technicians - answerTrained in either certain equipment, specialties, or to assist with
patients! For example, a respiratory technician helps the ER with emergency cases,
coming in where patients can't breathe and require respiratory equipment.
medical scribe - answerResponsible for charting the patient's visit and making sure it's
accurate and represents the providers efforts and what the patient told us. The chart
should make sense with what the patient came in with and their diagnosis! While
scribes don't do patient care, we make sure that patient's are taken care of by us taking
care of the provider!
tachy - answerfast
brady - answerslow
hyper - answerabove
hypo - answerbelow
itis - answerinfection/inflammation
osis - answerdisease of
ectomy - answersurgical removal of
arthro - answerjoint
osteo - answerbone
, chole - answerbile
otomy - answerhole or opening
algia - answerpain
subjective - answerwhat the patient tells us, ex. pain
objective - answerwhat the provider and results tell us, ex. tenderness
medical history - answerany prior medical problems that include chronic medical
problems, past surgeries, allergies to medications
family history - answerdirect family members with a medical problem and includes all of
the same medical histories; always note age of family history to determine if genetic
social history - answerany history that occurs in daily life including alcohol use, smoking
or tobacco/nicotine, occupation, and living status
high blood pressure - answerHypertension (HTN)
high cholesterol - answerHyperlipidemia (HLD)
diabetes - answerDiabetes Mellitus (DM)
only pills for diabetes - answerNon-Insulin dependent diabetes Mellitus (NIDDM) (type
II)
insulin shots for diabetes - answerInsulin Dependent Diabetes Mellitus (IDDM) (type I or
type II)
cancer - answercancer or carcinoma (CA)
heart disease - answerCoronary Artery Disease (CAD)
heart attack - answerMyocardial Infarction (MI) and CAD
heart failure - answerCongestive Heart Failure (CHF)
abnormal rhythm - answerArrhythmias, ex. atrial fibrillation
asthma - answerasthma
Emphysema/Chronic Bronchitis - answerChronic Obstructive Pulmonary Disease
(COPD)
