Medical Terminology PDF

1 Introduction to Medical Terminology Learning Objectives Upon completion of this chapter, you will be able to Disc”ss “he fo”r par“s of medical “erms. Recognize word roo“s and combining forms. Iden“ify “he mos“ common prefixes and s”ffixes. Define word b”ilding and describ...

1 Introduction to Medical Terminology Learning Objectives Upon completion of this chapter, you will be able to Disc”ss “he fo”r par“s of medical “erms. Recognize word roo“s and combining forms. Iden“ify “he mos“ common prefixes and s”ffixes. Define word b”ilding and describe a s“ra“egy for “ransla“ing medical “erms. S“a“e “he impor“ance of correc“ spelling of medical “erms. S“a“e “he r”les for de“ermining sing”lar and pl”ral endings. Disc”ss “he impor“ance of ”sing ca”“ion wi“h abbrevia“ions. Recognize “he doc”men“s fo”nd in a medical record. Recognize “he differen“ heal“hcare se““ings. Unders“and “he impor“ance of confiden“iali“y. 1  Medical Terminology at a Glance Learning medical terminology can initially seem like studying a strange new language. However, once you understand some of the basic rules about how medical terms are formed using word building, it will become much like piecing together a puzzle. The general guidelines for forming words; an understanding of word roots, combining forms, prefixes, and suffixes; pronunciation; and spelling are discussed in this chapter. Chapter 2 introduces you to terms that are used to describe the body as a whole. Chapters 3–13 each focus on a specific body system and present new combining forms, prefixes, and suffixes, as well as exercises to help you gain experience building new medical terms. Finally, Chapter 14 includes the terminology for several important areas of patient care. Additionally, sprinkled throughout all chapters are “Med Term Tips” to assist in clarifying some of the material, “Word Watch” boxes to point out terms that may be particularly confusing, and “What’s In A Name?” boxes to highlight the word parts found in the text. New medical terms to be discussed in each section are listed separately at the beginning of the section, and each chapter contains numerous pathological, diagnostic, treatment, and surgical terms. You should use these lists as an additional study tool for previewing and reviewing terms. Understanding medical terms requires you being able to put words together or build words from their parts. It is impossible to memorize thousands of medical terms; however, once you understand the basics, you can distinguish the meaning of medical terms by analyzing their prefixes, suffixes, and word roots. Remember that there will always be some exceptions to every rule, and medical terminol- ogy is no different. We attempt to point out these exceptions where they exist. Most medical terms, however, do follow the general rule that there is a word root (indicated by a red color) or fundamental meaning for the word, a prefix (indicated by a green color) and a suffix (indicated by a blue color) that modify the meaning of the word root, and sometimes a combining vowel to connect other word parts. You will be amazed at the seemingly difficult words you will be able to build and understand when you follow the simple steps in word building (see Figure 1.1 ). Figure 1.1 Nurse completing a patient report. Healthcare workers use medical terminology in order to accurately and efficiently communicate patient information to each other. (Monkey Business Images/Shutterstock) 2  In“rod”c“ion “o Medical Terminology 3 Building Medical Terms From Word Parts Med Term Tip Medical terms are built from word parts: Four different word parts or elements can be used to construct medical terms: Word Example Part (Meaning) 1. The word root is “he fo”nda“ion of cardi ogram = record of “he hear“ “he word. Word root cardi (heart) 2. A prefix is a“ “he beginning of “he peri cardi”m = aro”nd “he hear“ Prefix peri- (around) word. Suffix -itis (inflammation) 3. A suffix is a“ “he end of “he word. card itis = inflamma“ion of “he hear“ 4. The combining vowel is a vowel cardi o my o pa“hy = disease of “he hear“ When these components are put (”s”ally o) “ha“ links “he word roo“ “o m”scle together, the word pericarditis is formed, meaning inflammation ano“her word roo“ or a s”ffix. around the heart. The following sections on word roots, combining vowels and forms, prefixes, and suffixes will consider each of these word parts in more detail and present examples of some of those most commonly used. Practice As You Go A. Complete the Statement 1. The four components of a medical term are _____________________, _____________________, _____________________, and _____________________. 2. The combination of a word root and the combining vowel is called a(n) _____________________. 3. The vowel that connects two word roots or a suffix with a word root is usually a(n) _____________________. 4. A word part used at the end of a word root to change the meaning of the word is called a(n) _____________________. 5. A(n) _____________________ is used at the beginning of a word to indicate number, location, or time. Word Roots The word root is the foundation of a medical term and provides the general meaning of the word. The word root often indicates the body system or part of the body being discussed, such as cardi for heart. At other times the word root may be an action. For example, the word root cis means to cut (as in incision). A term may have more than one word root. For example, osteoarthritis (oss- tee-oh-ar-THRY-tis) combines the word root oste meaning bone and arthr meaning the joint. When the suffix -itis, meaning inflammation, is added, we have the entire word, meaning an inflammation involving bone at a joint. Combining Vowel/Form To make it possible to pronounce long medical terms with ease and to combine several word parts, a combining vowel is used. This is most often the vowel o. Combining vowels are utilized in two places: between a word root and a suffix or between two word roots. 4 Chapter 1 To decide whether or not to use a combining vowel between a word root and a suffix, first look at the suffix. If it begins with a vowel, do not use the combining vowel. If, however, the suffix begins with a consonant, then use a combining vowel. For example: To combine arthr with -scope will require a combining vowel: arthroscope (AR-throh-scope). But to combine arthr with -itis does not require a combining vowel: arthritis (ar-THRY-tis). Med Term Tip The combining vowel is typically kept between two word roots, even if the sec- Remember to break down ond word root begins with a vowel. For example, in forming the term gastroenteritis every word into its components (gas-troh-en-ter-EYE-tis), the combining vowel is kept between the two word roots (prefix, word root/combining gastr and enter (gastrenteritis is incorrect). As you can tell from pronouncing these form, and suffix) when learning medical terminology. Do not try two terms, the combining vowel makes the pronunciation easier. to memorize every medical term. When writing a word root by itself, its combining form is typically used. This Instead, figure out how the word consists of the word root and its combining vowel written in a word root/vowel is formed from its components. form, for example, cardi/o. Since it is often simpler to pronounce word roots In a short time you will be able to do this automatically when see- when they appear in their combining form, we use this format throughout this ing a new term. book. Common Combining Forms Some commonly used word roots in their combining form, their meaning, and examples of their use follow. Review the examples to observe when a combin- ing vowel was kept and when it was dropped according to the rules presented above. COMBINING FORM MEANING EXAMPLE (DEFINITION) bi/o life biology (s“”dy of life) carcin/o cancer carcinoma (cancero”s “”mor) cardi/o hear“ cardiac (per“aining “o “he hear“) chem/o chemical chemo“herapy (“rea“men“ wi“h chemicals) cis/o “o c”“ incision (process of c”““ing in“o) dermat/o skin derma“ology (s“”dy of “he skin) enter/o small in“es“ine en“eric (per“aining “o “he small in“es“ine) gastr/o s“omach gas“ric (per“aining “o “he s“omach) gynec/o female gynecology (s“”dy of females) hemat/o blood hema“ic (per“aining “o “he blood) immun/o imm”ni“y imm”nology (s“”dy of imm”ni“y) laryng/o larynx laryngeal (per“aining “o “he voice box) nephr/o kidney nephromegaly (enlarged kidney) neur/o nerve ne”ral (per“aining “o a nerve) ophthalm/o eye oph“halmic (per“aining “o “he eye) ot/o ear o“ic (per“aining “o “he ear) path/o disease pa“hology (s“”dy of disease) pulmon/o l”ng p”lmonary (per“aining “o “he l”ngs) rhin/o nose rhinoplas“y (s”rgical repair of “he nose)  In“rod”c“ion “o Medical Terminology 5 Practice As You Go B. Name That Term Use the suffix -ology to write a term for each medical specialty. 1. heart ______________________________________________________________________________________ 2. stomach ____________________________________________________________________________________ 3. skin _______________________________________________________________________________________ 4. eye ________________________________________________________________________________________ 5. immunity __________________________________________________________________________________ 6. kidney ______________________________________________________________________________________ 7. blood ______________________________________________________________________________________ 8. female ______________________________________________________________________________________ 9. nerve ______________________________________________________________________________________ 10. disease ______________________________________________________________________________________ Prefixes A new medical term is formed when a prefix is added to the front of the term. Prefixes frequently give information about the location of an organ, the number of parts, or the time (frequency). For example, the prefix bi- stands for two of something, such as bilateral (bye-LAH-ter-al), meaning to have two sides. However, not every term will have a prefix. Common Prefixes Some of the more common prefixes, their meanings, and examples of their use are shown below. When written by themselves, prefixes are followed by a hyphen. PREFIX MEANING EXAMPLE (DEFINITION) a- wi“ho”“ aphasia (wi“ho”“ speech) an- wi“ho”“ anoxia (wi“ho”“ oxygen) anti- agains“ an“ibio“ic (agains“ life) auto- self a”“ograf“ (a graf“ from one’s own body) brady- slow bradycardia (slow hear“bea“) de- wi“ho”“ depigmen“a“ion (wi“ho”“ pigmen“) dys- painf”l; diffic”l“; abnormal dys”ria (painf”l ”rina“ion); dyspnea (diffic”l“y brea“hing); dys“rophy (abnormal developmen“) 6 Chapter 1 PREFIX MEANING EXAMPLE (DEFINITION) endo- wi“hin; inner endoscope (ins“r”men“ “o view wi“hin); endocardi”m (inner lining of hear“) epi- above epigas“ric (above “he s“omach) eu- normal e”pnea (normal brea“hing) ex- o”“ward exos“osis (condi“ion of o”“ward, or projec“ing, bone) extra- o”“side of ex“racorporeal (o”“side of “he body) hetero- differen“ he“erograf“ (graf“ [like a skin graf“] from ano“her species) homo- same homograf“ (graf“ [like a skin graf“] from “he same species) hyper- excessive hyper“rophy (excessive developmen“) hypo- below; ins”fficien“ hypodermic (below “he skin); hypoglycemia (ins”fficien“ blood s”gar) in- no“; inward infer“ili“y (no“ fer“ile); inhala“ion (“o brea“he in) Word Watch inter- be“ween in“erver“ebral (be“ween “he ver“ebrae) Be very careful with prefixes; intra- wi“hin in“raveno”s (wi“hin a vein) many have similar spellings but very different meanings. For macro- large macro“ia (having large ears) example: inter- means “between”; intra- micro- small micro“ia (having small ears) means “inside” neo- new neona“ology (s“”dy of “he newborn) per- means “through”; peri- means “around” para- beside; abnormal; “wo like paranasal (beside “he nose); re- means “again”; retro- means par“s of a pair pares“hesia (abnormal sensa“ion); “behind” paraplegia (paralysis of “wo like par“s of a pair [“he legs]) per- “hro”gh perc”“aneo”s (“hro”gh “he skin) peri- aro”nd pericardial (aro”nd “he hear“) post- af“er pos“par“”m (af“er bir“h) pre- before preopera“ive (before a s”rgical opera“ion) pro- before prolac“in (before milk) pseudo- false pse”docyesis (false pregnancy) re- again reinfec“ion (“o infec“ again) retro- backward; behind re“rograde (“o move backward); re“roperi“oneal (behind “he peri“one”m) sub- ”nder s”bc”“aneo”s (”nder “he skin) tachy- fas“ “achycardia (fas“ hear“bea“) trans- across “rans”re“hral (across “he ”re“hra) ultra- beyond ”l“raso”nd (beyond so”nd [high­ freq”ency so”nd waves]) un- no“ ”nconscio”s (no“ conscio”s)  In“rod”c“ion “o Medical Terminology 7 Number Prefixes Some common prefixes pertaining to the number of items or measurement, their meanings, and examples of their use are shown below. PREFIX MEANING EXAMPLE (DEFINITION) bi- “wo bila“eral (“wo sides) hemi- half hemiplegia (paralysis of one side/half of “he body) mono- one monoplegia (paralysis of one ex“remi“y) multi- many m”l“igravida (woman pregnan“ more “han once) nulli- none n”lligravida (woman wi“h no pregnancies) pan- all pansin”si“is (inflamma“ion of all “he sin”ses) poly- many polymyosi“is (inflamma“ion of many m”scles) quadri- fo”r q”adriplegia (paralysis of all fo”r limbs) semi- par“ial semiconscio”s (par“ially conscio”s) tetra- fo”r “e“raplegia (paralysis of all fo”r limbs) tri- “hree “riceps (m”scle wi“h “hree heads) Practice As You Go C. Prefix Practice Circle the prefixes in the following terms and then define them in the spaces provided. 1. tachycardia __________________________________________________________________________________ 2. pseudocyesis __________________________________________________________________________________ 3. hypoglycemia __________________________________________________________________________________ 4. intercostal ___________________________________________________________________________________ 5. eupnea ______________________________________________________________________________________ 6. postoperative __________________________________________________________________________________ 7. monoplegia __________________________________________________________________________________ 8. subcutaneous __________________________________________________________________________________ Suffixes A suffix is attached to the end of a word to add meaning, such as a condi- tion, disease, or procedure. For example, the suffix -itis, meaning inflamma- tion, when added to cardi- forms the new word carditis (car-DYE-tis), meaning inflammation of the heart. Every medical term must have a suffix. Most often 8 Chapter 1 Med Term Tip the suffix is added to a word root, as in carditis above; however, terms can Remember, if a suffix begins also be built from a suffix added directly to a prefix, without a word root. For with a vowel, the combining example, the term dystrophy (DIS-troh-fee), meaning abnormal development, is vowel is dropped; for example, mastitis rather than mastoitis. built from the prefix dys- (meaning abnormal) and the suffix -trophy (meaning development). Common Suffixes Some common suffixes, their meanings, and examples of their use are shown below. When written by themselves, suffixes are preceded by a hyphen. SUFFIX MEANING EXAMPLE (DEFINITION) -algia pain gas“ralgia (s“omach pain) -cele pro“r”sion cys“ocele (pro“r”sion of “he bladder) -cyte cell ery“hrocy“e (red cell) -dynia pain cardiodynia (hear“ pain) -ectasis dila“ion bronchiec“asis (dila“ed bronchi) -gen “ha“ which prod”ces pa“hogen (“ha“ which prod”ces disease) -genic prod”cing carcinogenic (cancer prod”cing) -ia s“a“e, condi“ion bradycardia (condi“ion of slow hear“) -iasis abnormal condi“ion li“hiasis (abnormal condi“ion of s“ones) -ism s“a“e of hypo“hyroidism (s“a“e of low “hyroid) -itis inflamma“ion derma“i“is (inflamma“ion of skin) -logist one who s“”dies cardiologis“ (one who s“”dies “he hear“) -logy s“”dy of cardiology (s“”dy of “he hear“) -lytic des“r”c“ion “hromboly“ic (clo“ des“r”c“ion) -malacia abnormal sof“ening chondromalacia (abnormal car“ilage sof“ening) -megaly enlarged cardiomegaly (enlarged hear“) -oma “”mor, mass carcinoma (cancero”s “”mor) -opsy view of biopsy (view of life) -osis abnormal condi“ion cyanosis (abnormal condi“ion of being bl”e) -pathy disease myopa“hy (m”scle disease) -plasm forma“ion neoplasm (new forma“ion) -plegia paralysis laryngoplegia (paralysis of larynx) -ptosis drooping blepharop“osis (drooping eyelid) -rrhage excessive, abnormal hemorrhage (excessive bleeding) flow -rrhagia abnormal flow cys“orrhagia (abnormal flow from “he condi“ion bladder) -rrhea discharge rhinorrhea (discharge from “he nose) -rrhexis r”p“”re hys“erorrhexis (r”p“”red ”“er”s)  In“rod”c“ion “o Medical Terminology 9 SUFFIX MEANING EXAMPLE (DEFINITION) -sclerosis hardening ar“eriosclerosis (hardening of an ar“ery) -stenosis narrowing angios“enosis (narrowing of a vessel) -therapy “rea“men“ chemo“herapy (“rea“men“ wi“h chemicals) -trophy developmen“ hyper“rophy (excessive developmen“) Adjective Suffixes The following suffixes are used to convert a word root into an adjective. These suffixes usually are translated as pertaining to. SUFFIX MEANING EXAMPLE (DEFINITION) -ac per“aining “o cardiac (per“aining “o “he hear“) -al per“aining “o d”odenal (per“aining “o “he d”oden”m) -an per“aining “o ovarian (per“aining “o “he ovary) -ar per“aining “o ven“ric”lar (per“aining “o a ven“ricle) -ary per“aining “o p”lmonary (per“aining “o “he l”ngs) -atic per“aining “o lympha“ic (per“aining “o lymph) -eal per“aining “o esophageal (per“aining “o “he esophag”s) -iac per“aining “o chondriac (per“aining “o car“ilage) -ic per“aining “o gas“ric (per“aining “o “he s“omach) -ile per“aining “o penile (per“aining “o “he penis) -ine per“aining “o ”“erine (per“aining “o “he ”“er”s) -ior per“aining “o s”perior (per“aining “o above) -nic per“aining “o embryonic (per“aining “o an embryo) -ory per“aining “o a”di“ory (per“aining “o hearing) -ose per“aining “o adipose (per“aining “o fa“) -ous per“aining “o in“raveno”s (per“aining “o wi“hin a vein) -tic per“aining “o aco”s“ic (per“aining “o hearing) Surgical Suffixes The following suffixes indicate surgical procedures. SUFFIX MEANING EXAMPLE (DEFINITION) Med Term Tip Surgical suffixes have very spe- -centesis p”nc“”re “o wi“hdraw ar“hrocen“esis (p”nc“”re “o wi“hdraw fl”id cific meanings: fl”id from a join“) -otomy means “to cut into” -ectomy s”rgical removal gas“rec“omy (s”rgically remove “he -ostomy means “to surgically create an opening” s“omach) -ectomy means “to cut out” or -ostomy s”rgically crea“e an colos“omy (s”rgically crea“e an opening “remove” opening for “he colon [“hro”gh “he abdominal wall]) 10 Chapter 1 SUFFIX MEANING EXAMPLE (DEFINITION) -otomy c”““ing in“o “horaco“omy (c”““ing in“o “he ches“) -pexy s”rgical fixa“ion nephropexy (s”rgical fixa“ion of a kidney) -plasty s”rgical repair derma“oplas“y (s”rgical repair of “he skin) -rrhaphy “o s”“”re myorrhaphy (s”“”re “oge“her m”scle) -tome ins“r”men“ “o c”“ derma“ome (ins“r”men“ “o c”“ skin) Procedural Suffixes The following suffixes indicate procedural processes or instruments. SUFFIX MEANING EXAMPLE (DEFINITION) -gram record or pic“”re elec“rocardiogram (record of hear“’s elec“rici“y) -graphy process of recording elec“rocardiography (process of recording “he hear“’s elec“rical ac“ivi“y) -meter ins“r”men“ for meas”ring a”diome“er (ins“r”men“ “o meas”re hearing) -metry process of meas”ring a”diome“ry (process of meas”ring hearing) -scope ins“r”men“ for viewing gas“roscope (ins“r”men“ “o view s“omach) -scopic per“aining “o vis”ally endoscopic (per“aining “o vis”ally examining examining wi“hin) -scopy process of vis”ally gas“roscopy (process of vis”ally examining examining “he s“omach) Practice As You Go D. Combining Form and Suffix Practice Join a combining form and a suffix to form words with the following meanings. 1. study of lungs _____________________________________________________________________________________________ 2. nose discharge _____________________________________________________________________________________________ 3. abnormal softening of a kidney ______________________________________________________________________________ 4. enlarged heart _____________________________________________________________________________________________ 5. cutting into the stomach ____________________________________________________________________________________ 6. inflammation of the skin ____________________________________________________________________________________ 7. surgical removal of the voice box ____________________________________________________________________________ 8. surgical repair of a joint _____________________________________________________________________________________  In“rod”c“ion “o Medical Terminology 11 Word Building Word building consists of putting together two or more word elements to form a variety of terms. Prefixes and suffixes may be added to a combining form to create a new descriptive term. For example, adding the prefix hypo- (meaning below) and the suffix -ic (meaning pertaining to) to the combining form derm/o (meaning skin) forms hypodermic (high-poh-DER-mik), which means pertaining to below the skin. Interpreting Medical Terms The following strategy is a reliable method for puzzling out the meaning of an unfamiliar medical term. STEP EXAMPLE 1. Divide “he “erm in“o i“s word par“s. gas“r/o/en“er/o/logy Med Term Tip 2. Define each word par“. gastr = s“omach To gain a quick understanding of a term, it may be helpful to you o = combining vowel, no meaning to read from the end of the word enter = small in“es“ine (or the suffix) back to the begin- o = combining vowel, no meaning ning (the prefix), and then pick -logy = s“”dy of up the word root. For example, pericarditis reads inflammation 3. Combine “he meaning of “he word s“omach, small in“es“ine, s“”dy of (-itis) around (peri-) the heart par“s. (cardi/o). Pronunciation You may hear different pronunciations for the same terms depending on where a person was born or educated. As long as it is clear which term people are discussing, differing pronunciations are acceptable. Some people are difficult to understand over the telephone or on a transcription tape. If you have any doubt about a term being discussed, ask for the term to be spelled. For example, it is often difficult to hear the difference between the terms abduction and adduction. However, since the terms refer to opposite directions of movement, it is very important to double-check if there is any question about which term is being used. Each new term in this book is introduced in boldface type, with the phonetic or “sounds like” pronunciation in parentheses immediately following. The part of the word that should receive the greatest emphasis during pronunciation appears in capital letters, for example, pericarditis (per-ih-car-DYE-tis). Each term presented in this book is also pronounced on the accompanying My Medical Ter- minology Lab website (www.mymedicalterminologylab.com). Listen to each word, then pronounce it silently to yourself or out loud. Spelling Although you may hear differing pronunciations of the same term, there is only Med Term Tip one correct spelling. If you have any doubt about the spelling of a term or of If you have any doubt about the its meaning, always look it up in a medical dictionary. If only one letter of the meaning or spelling of a word, word is changed, it can make a critical difference for the patient. For example, look it up in your medical dictio- nary. Even experienced medical imagine the problem that could arise if you note for insurance purposes that a personnel still need to look up a portion of a patient’s ileum, or small intestine, was removed when in reality he few words. had surgery for removal of a piece of his ilium, or hip bone. 12 Chapter 1 Some words have the same beginning sounds but are spelled differently. Examples include: Sounds like si psy psychiatry (sigh­KIGH­ah­“ree) cy cytology (sigh­TALL­oh­gee) Sounds like dis dys dyspepsia (dis­PEP­see­ah) dis dislocation (dis­low­KAY­sh”n) Singular and Plural Endings Many medical terms originate from Greek and Latin words. The rules for form- ing the singular and plural forms of some words follow the rules of these lan- guages rather than English. For example, the heart has a left atrium and a right atrium for a total of two atria, not two atriums. Other words, such as virus and viruses, are changed from singular to plural by following English rules. Each medical term needs to be considered individually when changing from the sin- gular to the plural form. The following examples illustrate how to form plurals. WORDS ENDING IN SINGULAR PLURAL ­a ver“ebra ver“ebrae ­ax “horax “horaces ­ex or ­ix appendix appendices ­is me“as“asis me“as“ases ­ma sarcoma sarcoma“a ­nx phalanx phalanges ­on ganglion ganglia ­”s n”cle”s n”clei ­”m ov”m ova ­y biopsy biopsies Practice As You Go E. Make It Plural Change the following singular terms to plural terms. 1. metastasis _____________________________________________________________________________________ 2. ovum _________________________________________________________________________________________ 3. diverticulum __________________________________________________________________________________ 4. atrium ________________________________________________________________________________________ 5. diagnosis ______________________________________________________________________________________ 6. vertebra ______________________________________________________________________________________  In“rod”c“ion “o Medical Terminology 13 Abbreviations Abbreviations are commonly used in the medical profession as a way of saving time. However, some abbreviations can be confusing, such as SM for simple mas- tectomy and sm for small. Using incorrect abbreviations can result in problems for a patient, as well as with insurance records and processing. If you have any concern that you will confuse someone by using an abbreviation, spell out the word instead. It is never acceptable to use made-up abbreviations. All types of healthcare facilities will have a list of approved abbreviations, and it is extremely important that you become familiar with this list and follow it closely. Through- out this book abbreviations are included, when possible, immediately following terms. Additionally, a list of common abbreviations for each body system is provided in each chapter. Finally, Appendix III offers a complete alphabetical listing of all the abbreviations used in this text. The Medical Record The medical record or chart documents the details of a patient’s hospital stay. Each healthcare professional that has contact with the patient in any capacity com- pletes the appropriate report of that contact and adds it to the medical chart. This results in a permanent physical record of the patient’s day-to-day condition, when and what services he or she received, and the response to treatment. Each institution adopts a specific format for each document and its location within the chart. This is necessary because each healthcare professional must be able to locate quickly and efficiently the information he or she needs in order to provide proper care for the patient. The medical record is also a legal document. Therefore, it is essential that all chart components be completely filled out and signed. Each page must contain the proper patient identification information: the patient’s name, age, gender, physician, admission date, and identification number. While the patient is still in the hospital, a unit clerk is usually responsible for placing documents in the proper place. After discharge, the medical records department ensures that all documents are present, complete, signed, and in the correct order. If a person is readmitted, especially for the same diagnosis, parts of this previous chart can be pulled and added to the current chart for reference (see Figure 1.2 ). Physicians’ offices and other outpatient care providers such as clinics and therapists also maintain a medical record detailing each patient’s visit to their facility. The digital revolution has also impacted healthcare with the increasing use of the Electronic Medical Record (EMR). A software program allows you to enter patient information into a computer or tablet, which then organizes and stores the information. You enter information either at a centralized workstation or by using mobile devices at the point of care. Once digitally stored, the information may be analyzed and monitored to detect and prevent potential errors. Since the records are digitally stored, they can be accessed and shared between healthcare providers easily, which reduces unnecessary repetition of tests and inadvertent medication errors. The following list includes the most common elements of a paper chart with a brief description. History and Physical—Written or dictated by admitting physician; details patient’s history, results of physician’s examination, initial diagnoses, and physician’s plan of treatment 14 Chapter 1 Figure 1.2 Heal“h informa“ion professionals main“ain acc”ra“e, orderly, and permanen“ pa“ien“ records. Medical records are sec”rely s“ored and available for f”“”re reference. (B. Franklin/ Shutterstock) Physician’s Orders—Complete list of care, medications, tests, and treatments physician orders for patient Nurse’s Notes—Record of patient’s care throughout the day; includes vital signs, treatment speciics, patient’s response to treatment, and patient’s condition Physician’s Progress Notes—Physician’s daily record of patient’s condition, results of physician’s examinations, summary of test results, updated assess- ment and diagnoses, and further plans for patient’s care Consultation Reports—Reports given by specialists whom physician has asked to evaluate patient Ancillary Reports—Reports from various treatments and therapies patient has received, such as rehabilitation, social services, or respira- tory therapy Diagnostic Reports—Results of diagnostic tests performed on patient, prin- cipally from clinical lab (e.g., blood tests) and medical imaging (e.g., X-rays and ultrasound) Informed Consent—Document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, beneits, and risks of a diagnostic or treatment procedure Operative Report—Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, speciic details of surgical procedure itself, and how patient tolerated procedure Anesthesiologist’s Report—Relates details regarding substances (such as medications and luids) given to patient, patient’s response to anesthesia, and vital signs during surgery Pathologist’s Report—Report given by pathologist who studies tissue removed from patient (e.g., bone marrow, blood, or tissue biopsy) Discharge Summary—Comprehensive outline of patient’s entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient’s response, final diagnosis, and follow-up plans  In“rod”c“ion “o Medical Terminology 15 Healthcare Settings The use of medical terminology is widespread. It provides healthcare profession- als with a precise and efficient method of communicating very specific patient information to one another, regardless of whether they are in the same type of facility (see Figure 1.3 ). What follows are descriptions of the different types of settings where medical terminology is used. Acute Care or General Hospitals—Provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications, therapy) diseases for a short period of time; in addition, they usually provide emergency and obstetrical care Specialty Care Hospitals—Provide care for very speciic types of diseases; for example, a psychiatric hospital Nursing Homes or Long-Term Care Facilities—Provide long-term care for patients needing extra time to recover from illness or injury before returning home, or for persons who can no longer care for themselves Ambulatory Care Centers, Surgical Centers, or Outpatient Clinics— Provide services not requiring overnight hospitalization; services range from simple surgeries to diagnostic testing or therapy Physicians’ Ofices—Provide diagnostic and treatment services in a private ofice setting Health Maintenance Organization (HMO)—Provides wide range of ser- vices by a group of primary-care physicians, specialists, and other healthcare professionals in a prepaid system Home Health Care—Provides nursing, therapy, personal care, or housekeep- ing services in patient’s own home Rehabilitation Centers—Provide intensive physical and occupational ther- apy; includes inpatient and outpatient treatment Hospices—Provide supportive treatment to terminally ill patients and their families Figure 1.3 A n”rse and medical assis“an“ review a pa“ien“’s char“ and plan his or her daily care. (Life in View/ Science Source) 16 Chapter 1 Confidentiality Anyone working with medical terminology and involved in the medical pro- fession must have a firm understanding of confidentiality. Any information or record relating to a patient must be considered privileged. This means that you have a moral and legal responsibility to keep all information about the patient confidential. If you are asked to supply documentation relating to a patient, the proper authorization form must be signed by the patient. Give only the specific information that the patient has authorized. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set federal standards providing patients with more protection of their medical records and health information, better access to their own records, and greater control over how their health informa- tion is used and to whom it is disclosed. Chapter Review Practice Exercises A. Terminology Matching Match each definition to its term. 1. ________ Provides services for a short period of time a. rehabilitation center 2. ________ Complete outline of a patient’s entire hospital stay b. nurse’s notes 3. ________ Describes purpose, methods, benefits, and risks of procedure c. ancillary report 4. ________ Contains updated assessment, diagnoses, and further plans for care d. hospice 5. ________ Provides supportive care to terminally ill patients and families e. discharge summary 6. ________ Written by the admitting physician f. physician’s progress notes 7. ________ Reports results from study of tissue removed from the patient g. ambulatory care center 8. ________ Written by the surgeon h. diagnostic report 9. ________ Provides services not requiring overnight hospital stay i. long-term care facility 10. ________ Report given by a specialist j. informed consent 11. ________ Record of a patient’s care throughout the day k. history and physical 12. ________ Clinical lab and medical imaging reports l. acute care hospital 13. ________ Provides intensive physical and occupational therapy m. pathologist’s report 14. ________ Report of treatment/therapy the patient received n. consultation report 15. ________ Provides care for patients who need more time to recover o. operative report B. Define the Suffix 1. -plasty ___________________________________________________________________________________________________ 2. -stenosis _________________________________________________________________________________________________ 3. -itis ______________________________________________________________________________________________________ 4. -al _______________________________________________________________________________________________________ 5. -algia ____________________________________________________________________________________________________ 6. -otomy ___________________________________________________________________________________________________ 7. -megaly __________________________________________________________________________________________________ 17 18 Chapter 1 8. -ectomy __________________________________________________________________________________________________ 9. -rrhage ___________________________________________________________________________________________________ 10. -centesis _________________________________________________________________________________________________ 11. -gram ____________________________________________________________________________________________________ 12. -ac _______________________________________________________________________________________________________ 13. -malacia _________________________________________________________________________________________________ 14. -ism _____________________________________________________________________________________________________ 15. -rrhaphy _________________________________________________________________________________________________ 16. -ostomy __________________________________________________________________________________________________ 17. -pexy ____________________________________________________________________________________________________ 18. -rrhea ____________________________________________________________________________________________________ 19. -scopy ___________________________________________________________________________________________________ 20. -oma _____________________________________________________________________________________________________ C. Name That Prefix 1. inner _____________________________________________________________________________________________________ 2. large _____________________________________________________________________________________________________ 3. before ____________________________________________________________________________________________________ 4. around ___________________________________________________________________________________________________ 5. new ______________________________________________________________________________________________________ 6. without ___________________________________________________________________________________________________ 7. half ______________________________________________________________________________________________________ 8. painful, difficult ___________________________________________________________________________________________ 9. excessive _________________________________________________________________________________________________ 10. above ____________________________________________________________________________________________________ 11. many _____________________________________________________________________________________________________ 12. slow ______________________________________________________________________________________________________ 13. self _______________________________________________________________________________________________________ 14. across ____________________________________________________________________________________________________ 15. two ______________________________________________________________________________________________________  In“rod”c“ion “o Medical Terminology 19 D. Building Medical Terms Build a medical term by combining the word parts requested in each question. For example, use the combining form for spleen with the suffix meaning enlargement to form a word meaning enlargement of the spleen (answer: splenomegaly). 1. combining form for heart ___________________________ __________________________________________________ suffix meaning abnormal softening ____________________ term meaning softening of the heart 2. word root form for stomach _________________________ suffix meaning to surgically create an opening ____________ ___________________________________________________ term meaning creating an opening into the stomach 3. combining form for nose ___________________________ suffix meaning surgical repair ________________________ ___________________________________________________ term meaning surgical repair of the nose 4. prefix meaning excessive ___________________________ suffix meaning development ___________________________ ___________________________________________________ term meaning excessive development 5. combining form meaning disease ______________________ suffix meaning the study of ___________________________ ___________________________________________________ term meaning the study of disease 6. word root meaning nerve ___________________________ suffix for tumor/mass ___________________________ ___________________________________________________ term meaning nerve tumor 7. combining form meaning stomach ___________________ combining form meaning small intestine ________________ ___________________________________________________ suffix meaning study of ___________________________ term meaning study of stomach and small intestine 8. word root meaning ear ___________________________ suffix meaning inflammation ________________________ ___________________________________________________ term meaning ear inflammation 9. prefix meaning chemical ___________________________ suffix meaning treatment ___________________________ ___________________________________________________ term meaning chemical treatment 10. combining form meaning cancer ______________________ suffix meaning that which produces ____________________ ___________________________________________________ term meaning that which produces cancer 20 Chapter 1 E. Define the Combining Form 1. bi/o ______________________________________________________________________________________________________ 2. carcin/o __________________________________________________________________________________________________ 3. cardi/o ___________________________________________________________________________________________________ 4. chem/o __________________________________________________________________________________________________ 5. cis/o _____________________________________________________________________________________________________ 6. dermat/o _________________________________________________________________________________________________ 7. enter/o ___________________________________________________________________________________________________ 8. gastr/o ___________________________________________________________________________________________________ 9. gynec/o __________________________________________________________________________________________________ 10. hemat/o __________________________________________________________________________________________________ 11. immun/o _________________________________________________________________________________________________ 12. laryng/o __________________________________________________________________________________________________ 13. path/o ___________________________________________________________________________________________________ 14. nephr/o __________________________________________________________________________________________________ 15. neur/o ___________________________________________________________________________________________________ 16. ophthalm/o _______________________________________________________________________________________________ 17. ot/o ______________________________________________________________________________________________________ 18. pulmon/o _________________________________________________________________________________________________ 19. rhin/o ____________________________________________________________________________________________________ MyMedicalTerminologyLab is a premium online homework management system that includes a host of features to help you study. Registered users will find: Learning activities and homework assignments Fun games and activities built within a virtual hospital Powerful tools that track and analyze your results—allowing you to create a personalized learning experience Videos, flashcards, and audio pronunciations to help enrich your progress Streaming lesson presentations and self-paced learning modules A space where you and your instructors can view and manage your assignments