Starting a career as a medical scribe can be an exciting step into the world of healthcare, especially for those considering becoming a physician, nurse, or healthcare administrator. Whether you’re working onsite in a clinic or using virtual medical scribe services, understanding the core vocabulary of the profession is essential. Mastery of medical terminology not only helps with accurate documentation but also improves communication between healthcare professionals and supports better patient care.

In this article, we’ll go over some of the key terms every beginner scribe should know, particularly those who may be working with a physician or a scribe nurse, either in-person or virtually.

1. HPI (History of Present Illness)

The HPI is a detailed account of the patient’s current condition. It includes the onset, duration, location, severity, and modifying factors related to the symptoms. A virtual medical scribe working from a remote location must pay close attention to the provider’s verbal cues to document a complete and accurate HPI.

2. ROS (Review of Systems)

This is a systematic checklist of symptoms grouped by body system. It helps the provider determine if the symptoms are localized or part of a broader issue. Knowing the ROS is vital when transcribing from audio or video feeds as part of virtual medical scribe services.

3. PE (Physical Examination)

PE refers to the provider’s findings during the patient’s exam. It includes information about the patient’s general appearance, heart sounds, lung function, and other physical assessments. A scribe nurse or virtual scribe must document these findings correctly, using the appropriate clinical terms.

4. Assessment and Plan (A/P)

The assessment is the provider’s diagnosis or impression of the patient’s condition. The plan outlines the steps for treatment or further testing. For example:

• Assessment: Acute sinusitis

• Plan: Prescribe antibiotics, increase fluid intake, follow up in 1 week

This is one of the most important parts of the medical note and often requires careful listening and clinical understanding by the scribe.

5. SOAP Note

A standard documentation format used in clinical settings:

• Subjective: What the patient reports

• Objective: What the provider observes

• Assessment: Diagnosis

• Plan: Next steps

Familiarity with this format is key for any scribe, especially those working in settings where virtual medical scribe services are implemented.

6. EMR (Electronic Medical Record)

An EMR is a digital version of a patient’s paper chart. Medical scribes must learn how to navigate different EMR platforms efficiently to record patient encounters in real-time. Both in-clinic scribes and those offering virtual medical scribe services use EMRs extensively.

7. Differential Diagnosis

This is a list of potential conditions that could be causing the patient’s symptoms. It helps providers think critically and rule out possibilities. A scribe should know how to recognize and accurately record these without jumping to conclusions.

8. ICD-10 and CPT Codes

ICD-10 codes are used to describe diagnoses, while CPT codes are used for billing procedures. While scribes may not always assign these codes, understanding what they represent can be helpful when working alongside a scribe nurse or medical billing team.

9. Vitals

Vital signs include temperature, pulse, respiration rate, and blood pressure. These are essential parts of any patient evaluation. Knowing abbreviations like T (temperature), HR (heart rate), RR (respiratory rate), and BP (blood pressure) is a must for any new scribe.

10. PMHx, PSHx, FHx, SHx

These shorthand terms refer to different types of patient histories:

• PMHx: Past medical history

• PSHx: Past surgical history

• FHx: Family history

• SHx: Social history

Being familiar with these abbreviations will make it easier to document patient information accurately and quickly.

Conclusion

Becoming a skilled medical scribe requires more than just fast typing. Whether you're working side-by-side with a physician or providing support through virtual medical scribe services, mastering the essential medical vocabulary is critical. Understanding terms like SOAP notes, differential diagnoses, and EMR systems enables scribes to produce accurate, high-quality documentation and contribute to efficient patient care. For those working with or as a scribe nurse, this foundational knowledge bridges the gap between clinical practice and administrative support, helping the entire healthcare team run more smoothly.