Medical Terminology for Scribes and Scribe Candidates (1).pdf

This packet marks the first step towards an exceptional opportunity that provides one-of-a-kind first-hand experience in the healthcare setting. We aim to provide our employees with a fun and rewarding job where they can gain first hand experience in medicine, observe a variety of patients, become v...

This packet marks the first step towards an exceptional opportunity that provides one-of-a-kind first-hand experience in the healthcare setting. We aim to provide our employees with a fun and rewarding job where they can gain first hand experience in medicine, observe a variety of patients, become versed in medical terminology and learn clinician decision making. What you’ll be doing As a scribe you will work one-on-one with a clinician functioning as their personal assistant. The scribe’s role is to lessen the clinician’s burden of documentation and organizational responsibility; therefore, improving the clinician's efficiency and allowing them to focus on caring for their patients. This job is second-to-none for direct exposure to medicine and life in healthcare. Because you are working alongside clinicians the potential to gain knowledge is limitless, dependent only on your motivation to learn. Though the work is intense, the experience is rewarding and full of excitement. The day of a scribe begins by arriving at your scheduled shift where you prepare your laptop and familiarize yourself with the patients you will see. When your clinician arrives, you see patients with the clinician and record the patient’s symptoms and medical history as the doctor asks the patient questions. The clinician then performs the physical examination and verbalizes the findings to you. After the physical exam the doctor informs you of the orders that will be placed for the patient including laboratory studies, radiology studies, and medication orders. You will document the assessment and plan as dictated by the clinician and get the patient ready for check-out. Your day as a scribe is also filled with miscellaneous tasks including looking up old medical records, radiology studies, placing phone calls, and transcribing instructions from the physician. The work environment is fast-paced and bustling and there is always new work to be done. Scribing is indeed strenuous; however, the experiences and direct exposure to medicine make this job fun and exciting! 1 What we need from you ScribeAmerica asks distinctive qualities from every employee. These include commitment, reliability, critical thinking, adaptability, organization, excellent communication skills, unwavering work ethic, diligent attentiveness and being customer service focused toward the clinician, eagerness to learn, professionalism/maturity, as well as excellent computer skills and typing speed of 50 wpm. Not only are these attributes necessary to succeed in a position in healthcare but our training regime is too rigorous to be completed without them. You will also need consistent availability to work a minimum of two shifts per week and we prefer candidates who can commit 1-2 years of working. A clinician will want one scribe during their full shift. (Clinician's shifts can range from 8-12 hours in length). It is important you provide us with very accurate times when you can work because we match you up with a group of clinicians that need a scribe during those times you are available and train you how to work with those specific clinicians. How we hire and train If you are motivated, capable, and committed ScribeAmerica will be a partner in your pursuits. Becoming a scribe is lucrative but it is not easily achieved. The process is rigorous and demanding; but those who succeed as scribes tout the benefits of extensive medical knowledge, personal experience, invaluable letters-of-reference, and first hand exposure to the field of medicine. 2 Medical Vocabulary Scribing is a unique, demanding job and genuinely difficult; it is not like volunteer-work. It is strenuous and even stressful at times. Before entering training we would like you to reflect if this job is something you will excel at, and most importantly, something you will enjoy. The next pages are a glimpse of the work that lies ahead, should you decide this job is for you. Consider this list as both a sample of the rigors of training as well as your first opportunity to demonstrate that you have the ability to succeed as a scribe. Anatomical Terms Anatomical Position To stand erect with arms at the sides and palms of the hands turned forward Anterior Situated in front of or directed toward the front C-spine Cervical spine (C1-C7) Diffuse Generalized; not localized to any specific location Distal Farther from the trunk of the body Epigastric Upper central region of the abdomen Fontanel Anatomical feature of an infant’s skull, the “soft-spot” Inferior Lower on the body, farther from the head L-spine Lumbar spine (L1-L5) Lateral Farther from the midline Left Lower Extremity (LLE) Left leg Left Lower Quadrant (LLQ) Left Lower Quadrant Of the abdomen Left Upper Extremity (LUE) Left arm Left Upper Quadrant (LUQ) Left Upper Quadrant of the abdomen Medial Nearer to the midline Palmar or Volar Palm side of hand or body Plantar Sole of foot Posterior or Dorsal Rear or back Prone Body position lying face down with forearms and hands turned palm side down Proximal Nearer to the trunk of the body Right Lower Extremity (RLE) Right leg Right Lower Quadrant (RLQ) Right Lower Quadrant of the abdomen Right Upper Extremity (RUE) Right arm Right Upper Quadrant (RUQ) Right Upper Quadrant of the abdomen Superficial Nearer to the surface (example: superficial abrasion) 3  Superior Higher on the body, nearer to the head Supine Body position lying face up Suprapubic Lower central region on the abdomen T-spine Thoracic spine (T1-T12) Timing Acute New onset, likely concerning. Opposite of chronic Acute on chronic New exacerbation of a chronic condition Chronic Long-standing, constant. Opposite of acute Fluctuating Symptoms that are always present but changing in severity, never fully resolving Intermittent Symptoms that completely resolve at times, but continue to return repeatedly Paroxysmal Occasional, sporadic, transient Resolved Gone, no longer existing Transient Resolving spontaneously after onset Charting A part of the medical chart that lists diseases and health conditions in your family that Family History (FHx) may put the patient at an increased risk of also having Health Insurance Portability and Federal law that provides national standards to protect sensitive patient health Accountability Act (HIPAA) information from being disclosed without the patient's consent or knowledge History of present illness (HPI) A part of the medical chart describing the development of the illness pt Patient r/o Rule Out (e.g. X-ray of the wrist to r/o fracture) A part of the medical chart that is a checklist of the symptoms the patient has or does Review of system (ROS) not have. The symptoms are grouped by body system (cardiovascular, skin, etc) s/p Status Post (after) example: Headache s/p fall A part of the chart addresses substance use, occupation, diet exercise, living situation, Social History (SHx) marital status, etc. Sx Symptoms Tx Treatment UTD Up to Date (example vaccination utd) WNL Within Normal Limits (normal, not of concern) Diagnosis (Dx) Abscess A collection of pus beneath the skin Appendicitis Dangerous infection of the appendix 4  Arthritis Inflammation of the joints Atrial fibrillation (A fib) Irregular and often very rapid heart rhythm (arrhythmia) Bell’s Palsy A localized facial nerve dysfunction that causes facial droop and numbness Bronchitis Inflammation/Infection of the bronchi (upper airway) Cancer (CA) Cancer, Carcinoma Cellulitis Infection of skin cells Stroke. Blood supply to the brain is restricted or absent due to hemorrhage or Cerebrovascular accident (CVA) occlusion of a vessel resulting in neurological damage and dysfunction Cholecystitis Inflammation of the gallbladder Cholelithiasis Production of gallstones Chronic obstructive pulmonary disease (COPD) Chronic inflammatory lung disease that causes obstructed airflow from the lungs Chronic renal failure (CRF) Decrease in the kidneys' ability to filter waste and fluid from the blood Cirrhosis Inflammation of an organ by degenerative changes, especially of the liver Congestive heart failure (CHF) Serious condition in which the heart doesn't pump blood as efficiently as it should Conjunctivitis Infection of the outer layer of the eye Coronary artery bypass graft (CABG) Procedure used to treat coronary artery disease Coronary artery disease (CAD) Buildup of plaque in the arteries that supply oxygen-rich blood to your heart Costochondritis Inflammation of the rib cartilage Croup Viral infection of the upper airway with a barking cough and often stridor Deep venous thrombosis (DVT) blood clot forms in a vein located deep inside your body, typically in the leg Dermatitis Inflammation of the skin Diverticulitis Acute inflammation of the diverticula pouches Ectopic pregnancy Egg developing outside the uterus extremely dangerous due to risk of rupture Endometriosis Presence of functioning endometrial tissue outside of the uterus Gastroenteritis General term for inflammation of the GI tract Gastroesophageal reflux Digestive disorder that occurs when acidic stomach juices, or food and fluids back up disease (GERD) from the stomach into the esophagus Gout Type of arthritis; diagnosed by ordering a uric acid level Hepatitis Inflammation of the liver Hyperglycemia High blood sugar due to diabetes Hyperlipidemia (HLD) High cholesterol Hypertension (HTN) High blood pressure (typically >140/90) Hypoglycemia Low blood-sugar Hypotension Low blood pressure (typically