Scribeamerica Outpatient Initial Examination

Front 1

SOAP

Back 1

Subjective, Objective, Assessment, Plan

Front 2

CABG

Back 2

Coronary Artery Bypass Graft

Front 3

CVA

Back 3

Cerebrovascular Accident

Front 4

DVT

Back 4

Deep Venous Thrombosis

Front 5

PE

Back 5

Pulmonary Embolism

Front 6

DM

Back 6

Diabetes Mellitus

Front 7

MI

Back 7

Myocardial Infarction

Front 8

CAD

Back 8

Coronary Artery Disease

Front 9

HTN

Back 9

Hypertension

Front 10

UTI

Back 10

Urinary Tract Infection

Front 11

N/V/D

Back 11

Nausea/Vomiting/Diarrhea

Front 12

HA

Back 12

Headache

Front 13

CP

Back 13

Chest Pain

Front 14

SOB

Back 14

Shortness of Breath

Front 15

Sx

Back 15

Symptoms or Surgery

Front 16

PO

Back 16

Per O's, By Mouth

Front 17

s/p

Back 17

Status Post

Front 18

LOC

Back 18

Loss/Level of Consciousness

Front 19

FHx

Back 19

Hamily History

Front 20

Abx

Back 20

Antibiotics

Front 21

HEENT

Back 21

Head, Eyes, Ears, Nose, Throat

Front 22

ROM

Back 22

Range of Motion

Front 23

pt

Back 23

Patient

Front 24

NKDA

Back 24

No Known Drug Allergies

Front 25

CXR

Back 25

Chest X-Ray

Front 26

RUQ

Back 26

Right Upper Quadrant

Front 27

LLE

Back 27

Left Lower Extremity

Front 28

HPI

Back 28

History of Present Illness

Front 29

LNMP

Back 29

Last Normal Menstrual Period

Front 30

BID

Back 30

Twice A Day

Front 31

Afebrile

Back 31

Without Fever

Front 32

Conjunctivitis

Back 32

Eye Infection

Front 33

Myalgia

Back 33

Muscle Pain/Ache

Front 34

Ecchymosis

Back 34

Bruising

Front 35

Bradycardia

Back 35

Slow Heartrate

Front 36

Medial

Back 36

Near(er) Midline

Front 37

Pallor

Back 37

Pale

Front 38

Pharyngitis

Back 38

Throat Infection

Front 39

Epistaxis

Back 39

Nose Bleed

Front 40

Sinusitis

Back 40

Sinus Infection

Front 41

Redness

Back 41

Erythema

Front 42

Swelling

Back 42

Edema

Front 43

Sweating

Back 43

Diaphoresis

Front 44

Scrape

Back 44

Abrasion

Front 45

Pus-like

Back 45

Purulent

Front 46

Stroke

Back 46

CVA

Front 47

Puke

Back 47

Emesis

Front 48

Room-spinning

Back 48

Vertigo

Front 49

Runny-nose

Back 49

Rhinorrhea

Front 50

Passing-out

Back 50

Syncope

Front 51

Ischemia

Back 51

Restriction of Blood Supply to Tissue

Front 52

Infarct

Back 52

Tissue Death Due to Loss of blood supply

Front 53

Benign

Back 53

Nothing of Concern

Front 54

Acute

Back 54

Rapid Onset, short course

Front 55

Chronic

Back 55

Long lasting

Front 56

Grossly

Back 56

Obviously

Front 57

Febrile

Back 57

The state of having a fever (more than 100.4)

Front 58

STEMI

Back 58

ST elevation myocardial infarction

Front 59

Hemorrhage

Back 59

Bleeding, usually excessive bleeding

Front 60

Hypoxia

Back 60

Inadequate oxygen supply

Front 61

c/o

Back 61

complains of

Front 62

I&D

Back 62

Incision and Drainage

Front 63

IVDA

Back 63

Intravenous Drug Abuse

Front 64

TIA

Back 64

Transient Ischemic Attack

Front 65

UTD

Back 65

Up to date

Front 66

qhs

Back 66

At Night

Front 67

Fx

Back 67

Fracture

Front 68

Tx

Back 68

Treatment

Front 69

H&H

Back 69

Hemoglobin and hematocrit

Front 70

G/P/Ab

Back 70

Gravida/para/abortion

Front 71

IUP

Back 71

Intrauterine Pregnancy

Front 72

DOE

Back 72

Dyspnea on Exertion

Front 73

How to increase efficiency of the provider you work with in the clinic

Back 73

1. Complete documentation

2. Look up old records

3. Place phone calls

4. Transcribe special instructions

Front 74

what do you think the suffix "-algia" means?

Back 74

pain or ache

Front 75

Doctor is verbalizing their physical exam findings to you. You don't recognize a word. What do you do?

Back 75

Write it down phonetically and google it. If you are not 100% confident as the provider