Medical Terminology for Health Care Professionals PDF

Medical Terminology FOR HEALTH CARE PROFESSIONALS 8th edition CHAPTER 1 Introduction to Medical...

Medical Terminology FOR HEALTH CARE PROFESSIONALS 8th edition CHAPTER 1 Introduction to Medical Terminology Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Learning Outcomes 1. Describe the fundamental elements that are used to build medical words. 2. List three guidelines that will assist you with the building and spelling medical words. 3. Explain the use of abbreviations when writing and documenting data. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Learning Outcomes 4. Analyze, build, spell, and pronounce medical words. 5. Identify and define selected abbreviations. 6. Describe selected medical and surgical specialties, giving the scope of practice and the physician’s title. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Learning Outcomes 7. Define the Health Insurance Portability and Accountability Act (HIPAA). 8. List and describe the general components of a patient’s medical record. 9. List and describe the four parts of the SOAP chart note record. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved Comprehension of Fundamental Word Structure Medical terminology is the study of terms that are used in the art and science of medicine. Because of advances in scientific computerized technology, many new terms are coined daily; however, most of these terms are composed of word parts that have their origins in ancient Greek or Latin. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved Fundamentals of Word Structure The fundamental elements in medical terminology are the component parts used to build medical words. The abbreviations used for component parts in this text are P for prefix, R for root, CF for combining form, and S for suffix. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Prefix Prefix means to fix before or to fix to the beginning of a word. A prefix can be a syllable or a group of syllables placed at the beginning of a word to alter or modify the meaning of the word or to create a new word. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Word Root A root is a word or word element from which other words are formed. It is the foundation of the word and conveys the central meaning of the word. It forms the base to which prefixes and suffixes are attached for word modification. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Combining Form A combining form is a word root to which a vowel has been added to link the root to the suffix or to another root. The vowel "o" is used more often than any other to make combining forms. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Suffix Suffix means to fasten on, beneath, or under. A suffix can be a syllable or group of syllables united with or placed at the end of a word to alter or modify the meaning of the word or to create a new word. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Principles of Component Parts As you learn definitions for prefixes, roots, combining forms, and suffixes, you will discover that some component parts have the same meanings as others, which can be traced to differences in the Greek or Latin words from which they originated. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Principles of Component Parts Most of the terms for the body's organs originated from Latin words, whereas terms describing diseases that affect these organs have their origins in Greek. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved Identification of Medical Words You will learn to distinguish among and select the appropriate component parts for the meaning of the word. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Spelling Medical words of Greek origin are often difficult to spell because many begin with a silent letter or have a silent letter within the word. Correct spelling is extremely important in medical terminology because the addition or omission of a single letter can change the meaning of the word. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Spelling Words that begin with silent letters. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Spelling A medical term that begins with a silent letter. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Spelling A single letter can change the meaning of a word to something entirely different. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Prefixes and Suffixes That are Frequently Misspelled Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Spelling Follow these guidelines for building and spelling medical words: – If the suffix begins with a vowel, drop the combining vowel from the combining form and add the suffix. – If the suffix begins with a consonant, keep the combining vowel and add the suffix to the combining form. – Keep the combining vowel between two or more roots in a term. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Formation of Plural Endings To change the following singular endings to plural endings, substitute the plural endings as illustrated. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Formation of Plural Endings To change the following singular endings to plural endings, substitute the plural endings as illustrated. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Use of Abbreviations An abbreviation is a process of shortening a word or phrase into appropriate letters. It is used as a form of communication in writing and documenting data. If there is any question about which abbreviation to use, it is best to spell out the word or phrase and not use an abbreviation. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Pronunciation A single accent mark (') is called a primary accent and is used with the syllable that has the strongest stress. A double accent mark (") is called a secondary accent and is given to syllables that are stressed less than primary syllables. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Pronunciation Diacritics are marks placed over or under vowels to indicate the long or short sound of the vowel. – Macron ( ¯ )  The long sound of the vowel. – Breve ( ˘ )  The short sound of the vowel. – Schwa ( ə )  Indicates the central vowel sound of most unstressed syllables. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Abate Abnormal Abscess Acute Adhesion Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Afferent Ambulatory Antidote Antipyretic Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Antiseptic Antitussive Apathy Asepsis Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Autoclave Autonomy Axillary Biopsy Cachexia Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Centigrade Centimeter Centrifuge Chemotherapy Chronic Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Diagnosis Diaphoresis Disease Disinfectant Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Efferent Empathy Epidemic Etiology Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Excision Febrile Gram Heterogeneous Illness Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Incision Kilogram Liter Macroscopic Malaise Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Malformation Malignant Maximal Microgram Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Microorganism Microscope Milligram Milliliter Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Minimal Multiform Necrosis Neopathy Oncology Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Pallor Palmar Paracentesis Prognosis Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Prophylactic Pyrogenic Radiology Rapport Syndrome Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Audio Pronunciations Thermometer Topography Triage Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Table 1.1 Selected Medical and Surgical Specialties Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Table 1.1 (continued) Selected Medical and Surgical Specialties Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Table 1.1 (continued) Selected Medical and Surgical Specialties Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Table 1.1 (continued) Selected Medical and Surgical Specialties Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Table 1.1 (continued) Selected Medical and Surgical Specialties Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Table 1-2 Types of Surgical Specialties with Description of Practice Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record The medical record is a written document of information describing a patient and his or her healthcare. The record contains the dates, observations, medical or surgical interventions, and treatment outcomes provided during hospitalization or a visit to a healthcare facility. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record It includes information that the patient provides concerning his or her symptoms (Sx) and medical history, results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans. The physical medical record belongs to the healthcare provider, but the information in it belongs to the patient. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Basis for planning care and treatment. Means by which doctors, nurses, and others caring for the patient can communicate. Legal document describing the care the patient received and can be used as evidence in court. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Means by which the patient or insurance company can verify that services billed were actually provided. Records may include private and confidential information such as family relationships, sexual behavior, substance abuse, and personal thoughts/feelings. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Information on record could influence a person’s credit, admission to educational institutions, and employment. Information may also affect a person’s ability to get health insurance or the rates paid for insurance coverage. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Health Insurance Portability and Accountability Act (HIPAA) – Set of rules passed in 1996 that must be followed by doctors, hospitals, and other healthcare providers to help ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Health Insurance Portability and Accountability Act (HIPAA) – Requires that all patients be able to access their own medical records, correct errors or omissions, and be informed about how personal information is shared or used and about privacy procedures. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record HIPAA encourages electronic transactions and requires safeguards to preserve confidentiality of health information. HIPAA protections cover health plans, healthcare clearinghouses, and healthcare providers who conduct certain financial and administrative transactions. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Types of Medical Records – Paper – Microfilm  photographs of records in a reduced size – Microfiche  sheets of microfilm – Electronic Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Electronic Health Record (EHR) – Electronic record of a person’s health- related information that is created, gathered, managed, and consulted by authorized healthcare clinicians and staff Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Electronic Health Record (EHR) – Information includes patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, lab data, radiology images, and personal data such as age, weight, and billing information. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Electronic Health Record (EHR) – Automates and streamlines the clinician’s workflow – Generated and maintained within an institution – Gives patients, physicians, and other healthcare providers, employers, or insurers access to a patient’s medical records across facilities Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Patient Data – Information that is provided by the patient and then updated as necessary, providing data that relates directly to the patient. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Medical History (Hx) – A document describing past and current history of all medical conditions experienced by the patient. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Physical Examination (PE) – A record that includes a current head-to- toe assessment of the patient’s physical condition. Consent Form – A signed document by the patient or legal guardian giving permission for treatment. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Informed Consent Form – A signed document by the patient or legal guardian that explains the purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed before undergoing a procedure. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Physician’s Orders – A record of the prescribed care, medications, tests, and treatments for a given patient. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Nurse’s Notes – A record of a patient’s care that includes vital signs, particularly temperature, pulse and respiration (TPR) and blood pressure (BP), and treatments, procedures, and patient’s responses to such care. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved Figure 1.1 The health care professional is making notes before entering patient information into the electronic health record. (Courtesy Pearson Education) Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Physician’s Progress Notes – Documentation given by the physician regarding the patient’s condition, results of the physician’s examination, summary of test results, plan of treatment, and updating of data as appropriate. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Consultation Reports – Documentation given by specialists whom the physician has asked to evaluate the patient. Ancillary/Miscellaneous Reports – Documentation of procedures or therapies provided during a patient’s care, such as physical therapy, respiratory therapy, or chemotherapy. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Diagnostic Tests/Laboratory Reports – Documents providing the results of all diagnostic and laboratory tests performed on the patient. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Operative Report – Documentation from the surgeon detailing the operation, including the preoperative and postoperative diagnosis, specific details of the surgical procedure, how well the patient tolerated the procedure, and any complications that occurred. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Anesthesiology Report – Documentation from the attending anesthesiologist or anesthetist that includes a detailed account of anesthesia during surgery, which drugs were used, dose and time given, patient response, monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that occurred. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Pathology Report – Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record Discharge Summary (also called Clinical Resumé, Clinical Summary, or Discharge Abstract) – Outline summary of the patient’s hospital care, including date of admission, diagnosis, course of treatment and patient’s response(s), test results, final diagnosis, follow-up plans, and date of discharge. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record SOAP (Subjective, Objective, Assessment, Plan): Chart Note – Subjective  Symptoms the patient feels and describes to the health care professional. Also includes the patient’s chief complaint. – Objective  Symptoms that can be observed; results of laboratory and diagnostic tests may be included. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  The Medical Record SOAP (Subjective, Objective, Assessment, Plan): Chart Note – Assessment  Interpretation of the subjective and objective findings. – Plan  Includes the management and treatment regimen for the patient. Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved  Abbreviations Medical Terminology for Health Care Professionals, 8e Copyright © 2015 by Pearson Education, Inc. Jane Rice All Rights Reserved