Medical Terminology and Documentation PPT

Medical Terminology and Documentation PSW 1023 Let’s learn some medical lingo! Learning Objectives Understand meaning of medical terms and abbreviations Understand medical terms used to describe the body Identify safe abbreviations to use Understand a 24hr clock and use in...

Medical Terminology and Documentation PSW 1023 Let’s learn some medical lingo! Learning Objectives Understand meaning of medical terms and abbreviations Understand medical terms used to describe the body Identify safe abbreviations to use Understand a 24hr clock and use in documentation Learn to identify objective and subjective information Practice narrative note writing Medical Terms Foreign language Difficult to pronounce Knowing medical terminology is important in your work Medical terms are made up of parts or word elements Common abbreviations are used throughout the health care system There could be legal ramifications if incorrect terms are used because charts are legal documents Part of words Prefixes placed at the beginning of a word and change the meaning of the word; combined with other words; never used alone Roots contain the basic meaning of the word; combined with another root or suffixes, usually by an “o,” called a combining vowel Suffixes placed at the end of a root to change the meaning of the word; not used alone Combining the parts of words Medical terms formed by combing word parts Can be combined with prefixes, other roots, or suffixes. Can be prefix and root Can be root and suffix Can be prefix, root, and suffix Can also be more complicated Understanding medical terms When translating medical terms, identify the prefix, root, and suffix Eg. Nephritis Root – Nephr(o) meaning kidney Suffix – itis meaning inflammation Therefore nephritis means inflammation of the kidney Examples Dyspnea Root is pnea (means breathing) Prefex is dys (mean difficulty) Therefore, dyspnea mean difficulty breathing Examples Endocarditis Root - card (heart) Prefix - endo (inner) Suffix - itis (inflammation Therefore, Endocarditis mean “inflammation of the inner part of the heart” What should you do if you don’t understand a term? How to describe parts of the body and directions in medical terms Abdominal Regions Directional Terms Directional Terms Retrieved from https://www.ezmedlearning.com/blog/anat omical-position-and-directional-terms Abdominal Regions The abdomen is divided into the following regions to help describe the location of body structures, pain, or discomfort: Right upper quadrant (RUQ) Left upper quadrant (LUQ) Right lower quadrant (RLQ) Left lower quadrant (LLQ) Quadrants of the Abdomen Retrieved fromElsevier, https://3d4medical.com/blog/abdominal-divisions Directional Terms Retrieved from https://www.ezmedlearning.com/blog/anat omical-position-and-directional-terms Directional Terms Retrieved from https://www.ezmedlearning.com/blog/anat omical-position-and-directional-terms Directional Terms Retrieved from https://www.ezmedlearning.com/blog/anat omical-position-and-directional-terms Directional Terms Directional Terms Summary video for directional terms https://youtu.be/t6-ueqFK1IE Abbreviations Shortened forms of words or phrases Must be official—should not be made up Save time and space Each employer has a list of accepted abbreviations Common abbreviations are used daily in all health care facilities NOT cyberspeak Abbreviations Why do we use them? What do you do if you don’t understand something? Abbreviations Pt. tolerated DAT today. Up in chair BID. C/O SOB when walking. No complaints of chest pain. O2sat 92% receiving Fi02 0.30 via NP. BM in AM. CXR ordered AP and Lateral. Do you understand this note? Abbreviations – Drug forms Abbreviations - related to care Full Term Acceptable Abbreviation Abdomen ABD, abd Gastrointestinal GI Height Ht Patient pt. Shortness of breath SOB Range of Motion ROM Activities as tolerated ATT Abbreviations - Routes ROUTES APPLICABLE ABBREVIATION orally (by mouth) PO/po topically (skin/membrane surface) top. subcutaneously (into the subcutaneous fat) subcut intramuscularly (into a muscle) IM intravenously (directly into the vein) IV nasogastric tube NG or NGT rectally (through the rectum) PR Abbreviations - Time Time Abbreviations before meals ac after meals pc immediately stat at bedtime hs every bedtime qhs when necessary prn Abbreviations - Time More Times every hour q1h every two hours q2h every three hours q3h every four hours q4h every six hours q6h every 8 hours q8h every twelve hours q12h Abbreviations - Time Time Abbreviations once a day daily twice a day b.i.d./B.I.D. three times a day t.i.d./T.I.D. four times a day q.i.d./Q.I.D Abbreviations – Vital Signs Vital signs VS Blood pressure BP Heart Rate HR Temperature T Celsius C Oxygen Saturation 02 sat Respiratory Rate RR Abbreviations MUST KNOW!! Nil Per Os nothing by mouth: NPO Why is this so important?? Telling Time Use a 24 hour clock Uses four-digit number for time First two digits are for the hour Last two digits are the minutes a.m.: begins at 0100 h for 1 a.m. noon: 1200h p.m.: ends at 2400h or 0000h for midnight 24 hour clock The abbreviations of “a.m.” and “p.m.” are not used in Universal time. The abbreviation of “h” or “hr” may be used to denote time and avoid confusion. No colon (:) is used when writing Universal time. How to tell time using a 24 hour clock https://youtu.be/6Ti72WkUDU4 Practice Change the following 12 hour time 24 hour time 6 pm 0030 hr 1700 hr 3 am Intro to Documentation Charting Record of care Legal requirement Documentation Focus on both subjective and objective data: What you observed, including symptoms the client reported to you What you did When you did it The client’s response Documentation Subjective Data versus Objective Data KNOW THE DIFFERENCE Documentation – Subjective Data anecdotal information from opinions, perceptions, or experiences. Examples of subjective data in healthcare include a patient's pain level and THEIR descriptions of symptoms. As a PSW, you can record subjective information by asking patients HOW THEY FEEL or what they notice about their own experiences. Subjective data has the following characteristics: It can describe how something looks. Different people may offer diverse data. The descriptions are qualitative. It allows free expression. Perceptions may change with context. Subjective Data Example Mr. Jones complained of knee pain when getting out of bed this morning. He stated that he feels stiff and old and can’t get moving like he used to. Objective Data FACTS that professionals gather through observation or measurement. ACCURATE regardless of the feelings or opinions of the person presenting or receiving the information. Examples include blood pressure and heart rate. PSW’s gather objective data through formal assessments, diagnostic procedures, or observation. Objective data has the following characteristics: It involves quantitative or numerical details. It remains the same in all contexts and circumstances. Multiple measurements produce the same result. It allows for concrete information sharing. Objective Data Example Mr. Jones vital signs are: BP 110/74, HR 60 bpm, RR 18, T 36.5ºC. Observed patient having difficulty getting out of bed and bending his Rt. Knee. Documentation Objective and subjective are opposites. Objective: It is raining. Subjective: I love the rain! Retrieved from https://skillstx.com/objective- vs-subjective/ Class activity In small groups in breakout rooms Complete the activity: Abbreviations, time telling and documentation 15 minutes Return to large group to review