Orthopedic & Medical Scribing Terms
What is CC?
- CC = calcaneocuboid (joint)
When to use .clinicfollowup?
- Establish patient, returning within the 3 year period. - If the patient is past 6 months post op, they will be considered to be a follow up patient (include the date of surgery in the follow up diagnosis).
When to use .spectrumbrace?
- For the custom molded AFO (used when he prescribes a custom brace, especially AZ braces)
When to use .clinicjointinjection?
- Joint injection or aspirations, if it is an aspiration, modify the note appropriately.
When to use .clinicxrnormaltar?
- Normal impression for total ankle replacements.
When to use .clinicxrnormalankle?
- Normal template for ankle ankles.
When to use .clinicpostopsurgical?
- Past the 12 week post op range, 3-6 months post op
When to use .clinicpreop?
- Patient presents for pre-operative appointment.
When to use .clinicnewinjury?
- Patient was seen in the emergency department/urgent care and is following up with Dr. Owens for further care - New fracture
When to use .clinicpostopglobal?
- Post op within the 90 day range, from the moment the patient walks out of surgery till the 12 weeks post op.
When to use .toenailablation?
- RARELY used and when it is, primarily used with Dillon.
When to use .clinicxrnormalfus?
- This is commonly used with fusions in post op range/past post op range.
When to use .dmesecondankle?
- Used when directed, or with discernment.
When to use .clinicxrhealingfx?
- Used with fractures in post op range or past the post op range.
When to use .clinicnewpatient
- When the patient is new to the clinic - If the patient has not been seen in the past 3 years - If the patient was being followed by a PA- C, and now is being referred to Dr. Owens.
When to use .dmefootankle?
- use when prescribed DME like fracture boot, ASO brace, or post op shoe
When to use .clinicpreopdiscussion?
- use when surgery is discussed in ANY note
When to use .oweoutside?
- use when you need the outside imaging template. Some new patients come with MRIs, CTs, EMG/NCS, bone scans, etc.
How many weeks is a post-op patient?
6-11 weeks
What is a DME with examples
Durable medical equipment: ASO brace, fracture boot or post op shoe
What does ORIF stand for?
Open reduction internal fixation : use rod, screws or plates
What is OAI?
Oregon Advanced Imaging
What is Mulder's click testing?
Tests for ganglion cysts.
What is VWF?
Von Willebrand Disease
What is AITFL?
anterior inferior talofibular ligament
What is ATFL ?
anterior talofibular ligament
What should you select as f/u on post-op 2-6 weeks? After 6 weeks?
as scheduled, PRN
What is ASA?
aspirin
What is AVN?
avascular necrosis
What is PO?
by mouth
What does DOI mean?
date of injury
What does DOS mean?
date of service
What is DIP?
distal interphalangeal joint
What is DS?
double strength
What is QD?
every day
What is QHS?
every night at bedtime
What is Q6H?
every six hours (replace the 6 with whatever number required)
What is GLF?
ground level fall
What are the 3 main parts of the foot?
hindfoot, midfoot , forefoot
What is Tinel's Sign/Test? What does a negative result look like?
if he taps on nerves and does not hurt, Tinel's sign is negative
What is ITFL?
inferior talofibular ligament
What is I&D?
irrigation and debridement
What is an Ambulatory device with examples
knee scooter, wheelchair, walker or crutches
What is LCL?
lateral collateral ligament
What is MDCO?
medial displacement calcaneal osteotomy
What is MTP?
metatarsophalangeal joint
What is MTHX?
methotrexate
What is MIS?
minimally invasive surgery
What is MVA?
motor vehicle accident
What is MCC?
motorcycle collision
What is NC?
naviculocuneiform (joint)
What is NTTP?
none tender to palpation
What is NSAID?
nonsteroidal anti-inflammatory drug
What is OCL?
osteochondral lesion
What is PPD?
packs per day
What is an antalgic gait?
painful gait, to limp
What is PTT?
posterior tibialis tendon
What is a met pad?
prescribed shoe modification devices used for relief of pressure on the metatarsal head
What is .clinicxrnormal?
provides 4 drop down options for normal X-ray templates for fusions, TAR, fractures, and general normal. Select appropriate where necessary.
What is PIP?
proximal interphalangeal (joint)
What is an IR protocol?
scheduled process using interventional radiology
How to screenshot?
shift, Microsoft button and s.
What do SLHR and DLHR stand for?
single-leg heel raise, double leg heel raise
What does s/p mean?
status post (op)
What is TN?
talonavicular (joint)
What is TMT?
tarsometatarsal (joint)
What is .oweoutsideimaging?
template for MRI and CT scans (Sometimes you can find the MRI/CT scan in the media tab in the chart review.)
What is TTP?
tender to palpation
Difference between tendon and ligament?
tendon: muscle to bone ligament: bone to bone
What is a TAR patient?
total ankle replacement
What is BID, TID, QID?
twice per day, thrice per day, x4 per day
Difference between varus and valgus?
varus: "bow legged" knees point out valgus: "knockneed" knees point in
What is .clinicxrayreview?
when he reviews previous X-rays. This needs to be in here so that he can bill at an appropriate level.
