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!

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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.

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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)

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 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

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 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 <100/65)

Insulin dependent diabetes

mellitus (IDDM) Diabetes requiring the use of insulin injections

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 Lymphangitis Inflammation of a lymphatic vessel; appears as red streaking
Multiple sclerosis Autoimmune disease affecting the brain and spinal cord
Myocardial infarction (MI) Death of cardiac muscle due to prolonged ischemia (Heart attack)

Nephrolithiasis / Renal calculi Kidney stone

Non-insulin dependent diabetes
mellitus (NIDDM) Diabetes not requiring the use of insulin injections
Otitis externa Infection of the outer ear (ear canal)
Otitis media (OM) Infection inner ear (behind the eardrum)
Pancreatitis Inflammation of the pancreas
Pelvic inflammatory disease (PID) Inflammation of a woman’s reproductive organs
Peptic ulcer disease (PUD) Ulcers developing in the stomach causing pain and emesis
Pericarditis Inflammation of the pericardium

Blood circulation disorder that causes the blood vessels (excluding the heart and
Peripheral vascular disease (PVD) brain) to narrow, block, or spasm
Pharyngitis Throat infection
Pneumonia Infiltrate (infection) inside the lung tissue
Pneumothorax Presence of air or gas in the pleural space; collapsed lung
Psoriasis Autoimmune skin disease. dry, scaly, red, itchy patches of skin
Pulmonary Embolism Blockage of the pulmonary artery or one of its branches due to a translocated clot
Pyelonephritis Infection on the kidneys
Sciatica Compression of sciatic nerve causing back pain with radiation to posterior leg
Sepsis Dangerous infection of the blood
Sinusitis Infection/inflammation of the sinuses
Tinea Fungal rash
Transient ischemic attack (TIA) Transient “mini-stroke”, neurological function is regained completely with time
Upper respiratory infection (URI) Contagious infection of the upper respiratory tract (sinuses, throat, lungs or airways)
Urinary tract infection (UTI) Infection in any part of the urinary system — kidneys, ureters, bladder and urethra

Labs and Imaging

Blood test that measures eight different substances to evaluate kidney function, fluid
Basic metabolic panel (BMP) and electrolyte balance, blood sugar levels, acid and base balance, and metabolism
Chest X-Ray (CXR) Images of your heart, lungs, blood vessels, airways, and bones of chest and spine
Blood test used to evaluate your overall health and detect a wide range of disorders,
Complete blood count (CBC) including anemia, infection and leukemia
Comprehensive Metabolic Panel Blood test that measures fourteen different substances (BMP + liver function
(CMP) evaluation)

Computerized Assisted X-ray procedure provides a two-dimensional cross-sectional scan of your body and is
Tomography (CT / CAT) used to find irregularities

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 A test that records the electrical signal from the heart to check for different heart
Electrocardiogram (EKG / ECG) conditions

Hemoglobin and Hematocrit

(H&H) Red blood cell measurements to evaluate anemia
Urine test to detect a wide range of disorders, such as urinary tract infections, kidney
Urinalysis (UA) disease and diabetes

Medicines
Abx Antibiotics
ASA Acetylsalicylic Acid (Aspirin)

BID Twice Daily

IM intramuscular (with respect to injections)

NKDA No Known Drug Allergies

NSAID Non Steroidal Anti-Inflammatory Drug (e.g. Ibuprofen, Motrin, etc)

PO Per Os (by mouth)

prn As needed

QHS At Every Bedtime

QID Four Times a Day

Rx Prescription
TID Three Times a Day

Constitutional
Afebrile Without fever
Ambulatory Able to move about, not confined to a bed
Cachectic Extremely skinny, bony, malnourished
Constitutional The general appearance and nature of a patient
A patient’s inability to tolerate their body-state, due to pain or respiratory failure. No
Distress Acute Distress (NAD) is commonly written if a patient looks comfortable.
Febrile Elevated body temperature, fever, indicative of infection
Lethargic Septic, very sick, about to die
Malaise Generalized discomfort or weakness
Non-toxic Appearing stable and at no risk of deterioration
Somnolent Appearing drowsy
Unkempt Poor self hygiene
Well developed Normal state of mental and body development

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 Eye
Conjunctiva Thin outer lining of the eye and eyelid
Cornea Transparent frontal aspect of the eye, covering both the iris and pupil
Extraocular muscles intact (EOMI) Testing that examines the function of the eye muscle

The use of an ophthalmoscope to look through the pupil and examine the interior
Fundoscopic exam surface of the posterior eye
Nystagmus Involuntary “shaking” eye movements
Ophthalmalgia Pain in the eye
Pale conjunctiva Pale inner aspect of the eyelid most often due to anemia
Periorbital ecchymosis Bruising around the eyes, indicative of trauma
Photophobia Light sensitivity

Pupils are Equal, Round, and

Reactive, to Light (PERRL) Common normal eye exam finding
Scleral icterus Yellowing of the sclera (whites of the eye) due to jaundice
Subconjunctival hemorrhage Blood in the white part of the eye

Ear, Nose, and Throat (ENT)

Cerumen Earwax
Dentition Teeth
Dry mucosa Dry tongue, mouth, and lips, indicating significant dehydration
Edentulous Without teeth
Epistaxis Nose bleed
Gingiva Gums
Nare Nostril
Oropharynx The back of the mouth, where it meets the throat
Otalgia Ear ache
Pharyngeal erythema Redness of the pharynx, indicating a throat infection
Rhinorrhea Clear nasal discharge. "Runny" nose
Tinnitus “Ringing in the ears”, the perception of ringing even with no external stimuli
TM erythema Redness of the TM, often indicative of infection
Tonsillar exudate Pus on the tonsils, indicating infection of the tonsils

Tonsillectomy &
Adenoidectomy (T&A) Tonsils and adenoids removal surgery
Tympanic membrane (TM) Tympanic membrane, the clear membrane inside the ear; (ear drum)

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 Neck
Carotid bruit Whooshing blood flow heard with auscultation (carotid narrowing or plaque)
Lymphadenopathy Enlarged lymph nodes
Meningismus Stiff neck/Signs of meningitis

Supple Flexible, not-stiff

Thyromegaly Enlarged thyroid
Jugular vein distention (JVD) Jugular vein distention, sign of heart dysfunction

Cardiovascular (CV)
Aneurysm Localized ballooning of a vessel due to a weakened vessel wall
Arrhythmia Irregular heartbeat
Artery Blood vessel carrying blood away from the heart, muscular, contractile
Bradycardia Slow heart rate (HR<60)
Cardiomegaly Enlarged heart
Coronary artery Artery that supplies the heart with blood

Dorsalis pedis pulse Pulse that is palpable on the dorsum (top) of the foot
Murmur Abnormal heart sound rated on 1-6 scale
Normal sinus rhythm (NSR) The rhythm of a healthy heart
Palpitation To beat rapidly, irregularly, or forcibly (usually relating to the heart)
Pulse exam Carotid, brachial, radial, femoral, popliteal, dorsalis pedis (DP) or posterior tibia (PT)
Regular rate and rhythm (RRR) Normal heart sounds with a regular rate (60-100 bpm)
Stenosis Narrowing of a body opening or passage
Tachycardia Fast heart rate (HR>100 bpm)
Thrombus Blood clot or blockage
Vein Vessel carrying blood towards the heart, soft, compressible

Respiratory / Pulmonary
Bradypnea Decreased respiratory rate
Clear to auscultation (CTA) No abnormal sounds when listening to the lungs with a stethoscope
Dyspnea Difficulty/labored breathing, shortness of breath
Dyspnea on exertion (DOE) Feeling short of breath during very light exercise (e.g. walking)
Hemoptysis Coughing up gross amounts of blood
Hypoxia Low oxygen saturation of the body, not enough oxygen in the blood
Pleurisy General term for pain with breathing
Rales Crackles; Wet crackling heard in the lungs, typically due to pneumonia or CHF

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 Rhonchi Sound of mucous rolling around in the bronchioles/bronchi

Shortness of breath (SOB) Air hunger, difficulty breathing, or breathlessness

Sputum Any mixed matter with the saliva that is passed through the mouth
Stridor Upper airway noise; common sign in croup
Tachypnea Increased respiratory rate
Wheezing High pitched sound heard in the lungs with asthmatics or lung disease

Gastrointestinal (GI)
Dyspepsia Indigestion
Dysphagia Difficulty swallowing
Emesis Vomiting

Hematemesis Gross amounts of blood in the vomit

Hematochezia Bright red blood in the stool
Hepatomegaly Enlarged liver
Hernia Protrusion of part of an internal organ or tissue bulges through a weak area of muscle
McBurney’s point RLQ point tenderness indicative of appendicitis
Melena Black tarry stool indicative of an upper GI bleed
Murphy’s sign Pain with palpation of the RUQ during a deep breath, indicative of cholecystitis

N/V/D Nausea/Vomiting/Diarrhea
Organomegaly Enlarged organ
Peritoneal signs (Rebound,
guarding, or rigidity ) Signs indicative of acute abdominal inflammation (peritonitis)
Splenomegaly Enlarged spleen

Genitourinary (GU)
Adnexal tenderness Tenderness of the ovaries during the pelvic exam indicative of ovarian cyst or torsion
C-section Cesarean Section
Cervical os The opening of the cervix; always will be closed unless passing tissue from the cervix
CVA tenderness Costovertebral Angle tenderness; tenderness over the kidney’s
Dysmenorrhea Painful menstruation
Dysuria Painful urination
Foley catheter A tube inserted through the urethra to drain urine, often left in place
Frequency Urinating often
Gravida (The # of times pregnant / Para (The # of live children born) / Abortion (The #
G / P / Ab of failed pregnancies)
Gravid The state of being pregnant; appearing pregnant

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 Hematuria Blood in the urine

When a fertilized egg implants and starts to develop within the uterus, where it is
Intrauterine pregnancy (IUP) supposed to be
Last normal menstrual period
(LNMP) The first day of one's period
OB/GYN Obstetrics and gynecology
Spotting Passing very small amounts of blood from the vagina
Urgency Abrupt onset of urge to urinate

Musculoskeletal
Arthralgias Joint aches
Atrophic Showing signs of tissue degradation or breakdown

Bony tenderness Tenderness of the bone indicative of a fracture

Deformity Visual abnormality of a bone or anatomical structure
Dislocation Disconnected joint; complete misalignment of the joint
Fracture (Fx) Broken bone
Kyphosis Hunchback, rounded thoracic convexity of the spine
Malleolus Bony prominence on each side of the ankle (medial malleolus and lateral malleolus)
Myalgia Muscular pain, “muscle aches”
Paraspinal tenderness Tenderness of the muscles beside the spine
Range of motion (ROM) Capability of a joint to go through its complete spectrum of movements
Vertebral point-tenderness Tenderness directly over the spine (vertebrae), increased likelihood of fracture

Integumentary / Skin
Abrasion Scrape of the skin due to something abrasive
Avulsion A forcible pulling away of a part or structure
Cyanosis Blue color of the skin due to lack of oxygen
Diaphoresis Sweating
Ecchymosis Bruising
Eczematous rash Dry, scaly skin consistent with eczema
Edema Swelling
Erythema / Erythematous Redness/Red
Fibrous membrane of connective tissue supporting and separating muscles and body
Fascia organs
Fluctuance Palpable fluid beneath the skin indicative of infection/pus
Raised area with underlying blood which occurs in tissue resulting from ruptured
Hematoma blood vessels

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 Incision and drainage (I&D) Procedure used to drain and abscess to relieve pain and speed healing

Induration Hardened area of tissue; soft tissue that becomes extremely firm
Keloid Hypertrophic scar; raised scar
Laceration Splitting of the skin due to trauma (a cut due to something sharp)
Maculopapular rash Rash that is both red and raised
Mottled Patchy skin color due to poor blood circulation
Pallor Pale skin typically due to anemia
Papular Raised bumps
Red or purple discolorations on the skin that do not blanch (lighten) on applying
Petechial rash pressure (a sign of meningitis)
Pitting edema Edema that retains an imprint when touched
Pruritic Itchy

Purulence / Purulent Pus/Pus-like

Serosanguinous Consisting of serum and blood.
Subungual Beneath nail
Slow return of the skin to its normal position after being pinched, a sign of either
Tenting dehydration or aging, or both
Turgor Skin elasticity (poor turgor is a sign of dehydration or age)
Ulcerations Blisters or open-sores
Urticarial rash / Wheals A patchy red, raised rash, consistent with allergic reactions
Vesicular rash Vesicles; fluid filled blisters (e.g. herpes)

Neurological
Absence of the ability to neurologically generate or understand language. Either
Aphasic inability to create words or inability to understand spoken words
Ataxia Loss of coordination
Cephalgia Headache
Epilepsy Seizure disorder
Facial asymmetry Drooping of one side of the face indicating neurological damage
Hemiparesis Weakness of one half of the body
Hemiplegia Paralysis of one half of the body
Loss of consciousness (LOC) Passing out
Meningitis Infection of the meninges, the outer lining of the brain and spinal cord
Moves all extremities (MAEx4) The patient moves their arms and legs normally, indicating normal motor function
Normal DTRs Normal deep tendon reflexes, rated as 2/4
Oriented x3 Oriented to person, place, and time
Paresthesia Abnormal tactile sensation often described as tingling, numbness, or pinpricking

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 Postictal The state of somnolence and decreased responsiveness after a seizure

Syncope "Passing out", loss of consciousness or fainting

Vertigo Room-spinning dizziness (not light-headed)

Psychological
Affect The expressed or observed emotional and social responses
Auditory hallucinations Hearing voices, noises, music, or sounds that are not actually real
Depressed Appearing sad, unhappy
Flat affect Lack of normal interaction, monotone, unemotional
Homicidal ideation Thoughts of killing another person
Suicidal ideation Thoughts of killing oneself

Tangential thoughts Thought processes that do not follow normal or logical progressions
Visual hallucinations Seeing objects, people, or things that do not actually exist

Miscellaneous
-ectomy (suffix) Surgical removal (e.g. tonsillectomy)
-itis (suffix) Inflammation (e.g. appendicitis)
-scopy (suffix) Viewing with a scope (e.g. colonoscopy)
Auscultation Listening with the stethoscope
Baseline The normal state of being for each specific patient
Benign Normal, of no danger to health
Tube inserted into vessels or body cavities to permit injection or withdrawal of fluids
Catheter or to keep a passage open
Differential Diagnosis The diseases that a physician is considering as the reason for the patient’s symptoms
Grossly Obviously; a lot; wholly
Hemorrhage Excessive or profuse bleeding
Infarct Area of dead tissue after a lack of blood supply (e.g. Myocardial Infarction)
Ischemia Lack of blood supply to a specific area
Palpation Examine by touch

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