General Medical Terminology

Acute - Sudden onset or short duration

Chronic - Long-lasting or recurring

Benign - Not harmful or cancerous

Malignant - Harmful; potentially cancerous

Idiopathic - Unknown cause

Etiology - Cause of disease

Pathology - Study of disease

Prognosis - Expected outcome

Differential diagnosis (DDx) - List of possible conditions explaining a patient's symptoms

 

Anatomical Directions (Important for Physical Exams)

Anterior - Front side of the body

Posterior - Back side of the body

Lateral - Side

Medial - Toward midline of the body

Proximal - Closer to trunk

Distal - Further from trunk, closer to extremities like hands or feet

Superior - Above

Inferior - Below

 

Vitals

BP - Blood pressure

HR - Heart rate

RR - Respiratory rate

Temp - Temperature

O2 sat/Pulse ox - Oxygen saturation

 

Common Abbreviations

c/o - Complains of

Hx - History

FHx - Family history

PMHx - Past medical history

SHx - Social history

ROS - Review of systems

PE - Physical exam

NAD - No acute distress

WNL - Within normal limits

R/O - Rule out

SOB - Shortness of breath

N/V - Nausea/vomiting

CP - Chest pain

AMS - Altered mental status

 

Labs/Imaging

CBC - Complete blood count; measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets. Used to detect infections, anemia, clotting problems, and more.

BMP - Basic metabolic panel; assesses electrolytes (Na⁺, K⁺, Cl⁻), kidney function (BUN, creatinine), and glucose levels. Used for hydration, kidney function, and diabetes screening.

CMP - Comprehensive metabolic panel; includes BMP plus liver enzymes (AST, ALT, ALP), bilirubin, and proteins (albumin, total protein). Gives a broader view of metabolic and liver function.

D-dimer – Measures clot breakdown products. Elevated levels may indicate a PE (pulmonary embolism) or DVT (deep vein thrombosis), but not specific.

PT/INR - Prothrombin Time / International Normalized Ratio; measures how long blood takes to clot. Used to monitor patients on blood thinners like warfarin.

PTT - Partial Thromboplastin Time; another test for blood clotting, especially for heparin therapy monitoring.

Troponin – Cardiac enzyme released when heart muscle is damaged. High levels suggest a heart attack (MI).

UA - Urinalysis; evaluates urine for signs of infection (UTI), blood, glucose, protein, or kidney disease.

CXR - Chest X-ray; visualizes lungs, heart, ribs. Commonly used to detect pneumonia, heart failure, pneumothorax, fractures.

CT - Computed tomography; cross-sectional images using X-rays. Used to evaluate head trauma, stroke, abdominal pain, chest pain, fractures, etc. Often enhanced with contrast.

MRI - Magnetic resonance imaging; uses magnetic fields to produce detailed images. Best for soft tissue: brain, spinal cord, joints, ligaments, and tumors.

EKG/ECG - Electrocardiogram; measures electrical activity of the heart. Used to diagnose arrhythmias, heart attacks, electrolyte issues.

XR - X-ray (General); used for imaging bones, chest, abdomen, joints. Lower resolution than CT, but quick and inexpensive.

Echo - Echocardiogram; ultrasound of the heart. Assesses heart function, valve problems, ejection fraction.

Lipid Panel – Measures cholesterol (LDL, HDL, total) and triglycerides. Used for heart disease risk assessment.

 

Common Diagnoses

HTN - Hypertension (high BP)

DM - Diabetes mellitus

CAD - Coronary artery disease

MI - Myocardial infarction (heart attack)

CVA - Stroke

TIA - Transient ischemic attack

CHF - Congestive heart failure

COPD - Chronic obstructive pulmonary disease

PNA - Pneumonia

UTI - Urinary tract infection

DKA - Diabetic ketoacidosis

 

Common Medications (IMPORTANT)

Antihypertensives - Lisinopril, Amlodipine, Hydrochlorothiazide

Antibiotics - Amoxicillin, Azithromycin, Flagyl, Keflex, Cefalexin, Doxycycline, Erythromycin

Anticoagulants - Warfarin, Eliquis, Plavix, Heparin, Xarelto, Apixaban

Analgesics - Tylenol, Ibuprofen, Morphine, Naproxen, Oxycodone

Diuretics - Furosemide (Lasix) 

 

Procedures

Intubation - Insertion of a breathing tube; to help a patient breathe when they cannot do so on their own (e.g. respiratory failure, surgery, overdose).

Lumbar puncture - Spinal tap; to diagnose conditions like meningitis, subarachnoid hemorrhage, or multiple sclerosis.

Laparoscopy - Minimally invasive abdominal surgery; used for diagnosing or treating conditions like appendicitis, gallbladder issues, or ectopic pregnancy.

Thoracentesis - Removing fluid from the chest; to relieve shortness of breath or diagnose the cause of a pleural effusion (fluid buildup).

Central line - Large IV into central vein; for giving long-term medications, fluids, or when peripheral IV access is difficult. Also used for measuring central venous pressure.

Pro Scribe Tip #1: Know Your Terms 

You will be expected to know medical terminology, not just recognize it, but actually spell it, say it out loud, and type it fast. My scribe training involved memorizing a general list of terms, especially ones heard often in the ED. But if you're working in a specialty (like ortho, derm, or GI), tailor your study list to fit that field.

Some of the hardest terms you'll encounter are physical exam findings, things like nystagmus, crepitus, or pronator drift, and providers often rattle them off at lightning speed outside the patient’s room, while you're still catching up. It can feel awkward to ask, “Can you spell that?” but trust me, it’s way better than getting it wrong in the note.

That said, don’t beat yourself up. You’re not in med school (yet), and no one expects you to be a walking dictionary. Just keep practicing. Say terms out loud, quiz yourself on spelling, and know that every scribe starts out feeling overwhelmed, and then gradually levels up.

 

Pro Scribe Tip #2: Doctors Are People Too (Just Really Tired Ones)

Working with physicians can be intimidating, especially if you’re a recent or current undergrad. Chances are, you’ll be younger than most of the staff, and definitely younger than the doctors, after all, they’ve gone through years of intense training and have the eye bags and experience to prove it.

So here’s the truth: some will be warm and chatty, some will be laser-focused and barely look up. And many are just plain exhausted. But don’t let that stop you from introducing yourself at the start of your shift. You don’t need to launch into small talk or try to become besties. A quick, professional hello goes a long way.

Doctors are often so focused on patients that they forget you're there to make their life easier. So gently remind them. Make your presence known early, and if the moment’s right, ask if they have any preferences for how you write their notes or whether they want you to follow them into every room.

And when they do start making conversation, which they often will once they have a breather, don’t be afraid to share a little about yourself. You’ll be surprised how many will take an interest in your goals, especially if you’re pre-med or considering a healthcare career.

Bottom line: don’t be invisible. Be professional, be available, and let them know you’ve got their back.

 

Pro Scribe Tip #3: Master the EMR. It’s Ugly, But It’s Home

Let’s be honest: EMRs are not designed with beauty, simplicity, or sanity in mind. They’re not cute. They’re not clean. They’re not intuitive. Most screens look like they were designed by a committee that hates both color coordination and new users.

But you’ve got to get familiar... fast. Spend time outside of the chaos clicking around, exploring different views, filters, and tabs. Learn how to pull up lab results, imaging, vitals, and past workups without fumbling. Because during a shift, your provider might turn to you in the middle of a patient encounter and say, “Can you pull up their old head CT?” or “What were their last three glucose readings?” and you don’t want to be stuck squinting at a sea of tabs like it’s a puzzle you’ve never seen before.

Your goal is to become your provider’s second hand, not someone they need to babysit or guide through the chart. The better you know the EMR, the more helpful, and impressive, you’ll be.

Bonus: once you really learn the system, you’ll be faster, more confident, and way less stressed. Ugly interface or not, it’s your new habitat, so make yourself at home.

 

https://www.typingtest.com is a great website that offers free typing tests and exercises to practice your typing skills! This is what my program used to test us on our typing speed during interviews, so I know that it works!