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1 Introduction to Medical Terminology
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Multimedia Directory Slide 52 Medical Transcriptionist Video
Slide 54 Patient Histories Video 1 Slide 55 Patient Histories Video 2 Slide 73 HIPAA Video
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Medical Terminology at a Glance
Studying medical terminology is like learning a new language Basic rules for building terms will help you both build and translate many different words You must be able to put words together or build words from their parts Like piecing together a puzzle
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Understanding Medical Terms
It is impossible to memorize all of the thousands of medical terms You can distinguish the meaning of many different words by analyzing the word parts Word roots Combining forms Prefixes Suffixes
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Figure 1. 1 Nurse completing a patient report
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.
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Basic Word Parts Word root is the fundamental meaning of the term
Prefixes and suffixes modify the word root Combining vowels connect other word parts Always exceptions to rules
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Medical Terms Are Built from Word Parts
Word root Prefix Suffix Combining form Example (Meaning) cardiogram (record of the heart) pericardium (around the heart) carditis (inflammation of the heart) cardiomyopathy (heart muscle disease)
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Word Root Foundation of the term General meaning of word
Often gives body system or part cardi = heart Or may be an action cis = to cut
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Word Root Medical terms may have more than one root
osteoarthritis Medical terms may be built without a word root hyper- = prefix meaning excessive -trophy = suffix meaning development hypertrophy = excessive development
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Combining Vowels Make it possible to pronounce long terms
Usually an “o” Combine two word parts: Between two word roots Between word root and suffix
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Combining Vowel Rules Between word root and suffix
If the suffix begins with a vowel Do not use a combining vowel Arthritis, not arthroitis If the suffix begins with a consonant Use a combining vowel Arthroscope, not arthrscope
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Combining Vowel Rules Combining vowel is typically kept between two word roots Even if the second word root begins with a vowel gastroenteritis, not gastrenteritis
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Combining Form Typically used to write word roots
Also use the word root/combining vowel format Examples: cardi/o arthr/o gastr/o
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Common Combining Forms
aden/o – gland carcin/o – cancer cardi/o – heart chem/o – chemical cis/o – to cut dermat/o – skin enter/o – small intestine gastr/o – stomach
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Common Combining Forms
gynec/o – female hemat/o – blood hydr/o – water immun/o – immunity laryng/o – voice box nephr/o – kidney neur/o – nerve ophthalm/o – eye
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Common Combining Forms
ot/o – ear path/o – disease pulmon/o – lung rhin/o – nose
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Prefix Added to the front of a term Adds meaning such as:
location of organ sub- = below number of parts mono- = one time (frequency) post- = after
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Prefix Not all medical terms have a prefix
When written by itself, followed by a hyphen intra- hyper- multi-
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Common Prefixes a- without, away from an- without
ante- before, in front of anti- against auto- self brady- slow contra- against de- without
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Common Prefixes dys- painful, difficult, abnormal endo- within, inner
epi- upon, over eso- inward eu- normal, good ex- external, outward exo- outward extra- outside of
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Common Prefixes hetero- different homo- same hydro- water
hyper- over, above hypo- under, below in- not, inward inter- among, between intra- within, inside
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Common Prefixes macro- micro- myo- neo- pan- para- per- peri-
large small to shut new all beside, near, abnormal, two like parts of a pair through around
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Common Prefixes post- after pre- before, in front of pro- before
pseudo- false retro- backward, behind sub- below, under supra- above tachy- fast
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Common Prefixes trans- through, across ultra- beyond, excess un- not
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Number Prefixes bi- two hemi- half mono- one multi- many nulli- none
poly- many primi- first quadri- four semi- partial, half tetra- four tri- three
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Suffix Attached to the end of a term Adds meaning such as:
condition -algia = pain disease -itis = inflammation procedure -ectomy = surgical removal
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Suffix All medical terms must have a suffix
Only mandatory word part When written by itself, precede with a hyphen -logy -sclerosis -cyte
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Common Suffixes -algia pain -cele hernia, protrusion -cyte cell
-dynia pain -ectasis dilatation -gen that which produces -genesis produces, generates -genic producing, produced by
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Common Suffixes -ia state, condition -iasis abnormal condition
-iatry medical treatment -ism state of -itis inflammation -logist one who studies -logy study of -lysis destruction
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Common Suffixes -lytic destruction -malacia abnormal softening
-megaly enlargement, large -oid resembling -oma tumor, mass -osis abnormal condition -pathy disease -phobia fear
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Common Suffixes -plasia development, growth
-plasm formation, development -ptosis drooping -rrhage excessive, abnormal flow -rrhagia abnormal flow condition -rrhea discharge, flow -rrhexis rupture -sclerosis hardening
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Common Suffixes -stenosis narrowing -therapy treatment
-trophy nourishment, development -ule small
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Adjective Suffixes Suffix may be used to convert a word root into a complete word Translation of these suffixes is pertaining to New word can then be used to modify another word
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Adjective Suffix Example
To state that a patient has an ulcer in his or her stomach: gastr/o = stomach -ic = pertaining to gastric = pertaining to the stomach gastric ulcer = ulcer found in the stomach
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Adjective Suffixes -ac -al -an -ar -ary -atic -eal -iac -ic -ile -ine
-ior -nic -ory -ose -ous -tic
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Surgical Suffixes -centesis puncture to withdraw fluid
-ectomy surgical removal -ostomy surgically create an opening -otomy cutting into -pexy surgical fixation -plasty surgical repair -rrhaphy suture
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Procedural Suffixes -gram record or picture
-graph instrument for recording -graphy process of recording -meter instrument for measuring -metry process of measuring -scope instrument for viewing -scopy process of visually examining
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Word Building Putting together several parts to form a variety of terms to convey the necessary information Begins with knowing the meaning of the various word parts in order to select the correct ones Always remember the rules regarding the location of each word part
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Word Building For example: Combine to form the term:
hypo- = below or under derm/o = meaning the skin -ic = meaning pertaining to Combine to form the term: Hypodermic Meaning: pertaining to under the skin
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Interpreting Medical Terms
Term to be translated gastroenterology Divide the term into its word parts gastr / o / enter / o / logy
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Interpreting Medical Terms
Define each word part gastr = stomach o = combining vowel, no meaning enter = small intestine -logy = study of Combine the meanings of the word parts study of the stomach and small intestine
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Pronunciation Will differ according to place of birth and education
When in doubt, ask for spelling New terms in the book are introduced in boldface type, with phonetic spelling in parentheses Stressed syllable will be in capital letters: pericarditis (per ih car DYE tis)
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Spelling Only one correct way to spell a term
Changing one letter can change the meaning of a word abduction (moving away) versus adduction (moving towards) ileum (small intestine) versus ilium (hip bone)
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Same Sounds Spelled Differently
Sounds like si psy psychiatry cy cytology Sounds like dis dys dyspepsia dis dislocation
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Singular and Plural Endings
Many medical terms come from Greek or Latin words Rules for forming plurals for these languages are different from English Plural of atrium is atria, not atriums Other words will use English rules Plural of ventricle is ventricles
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General Rules for Plurals
Word Ends In -a -ax -ex or -ix -is -ma -nx -on -um -us -y Singular vertebra thorax appendix metastasis sarcoma phalanx ganglion ovum nucleus biopsy Plural vertebrae thoraces appendices metastases sarcomata phalanges ganglia ova nuclei biopsies
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Abbreviations Commonly used to save time Can be confusing
If you are concerned about confusion, spell out the term Do not use your own personal abbreviations
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Figure 1.2 Health information professionals maintain accurate, orderly, and permanent patient records. Medical records are securely stored and available for future reference.
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The Medical Record Documents details of hospital stay
Patient’s day-to-day condition When and what services were provided Response to treatment All personnel with patient contact complete the appropriate report Medical records department ensures that all documents are present, complete, signed, and in order
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The Electronic Medical Record (EMR)
A software program Allows entry of patient information into a computer
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The Electronic Medical Record (EMR)
Once digitally stored, information can be: Analyzed and monitored to detect and prevent potential errors Easily accessed and shared between healthcare providers Reduces repeating tests unnecessarily Reduces inadvertent medication errors
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Medical Transcriptionist Video
Click on the screenshot to view a video on the duties of the medical transcriptionist. Back to Directory
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Common Elements of the Medical Record
History and Physical Written by admitting physician Details patient’s: History Exam results Initial diagnosis Physician’s plan of treatment Physician’s Orders Ordered by the doctor Complete list of: Care Medications Tests Treatments
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Patient Histories Video 1
Click on the screenshot to view a video on the correct manner while taking patient histories. Back to Directory
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Patient Histories Video 2
Click on the screenshot to view a video on the wrong manner while taking patient histories. Back to Directory
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Common Elements of the Medical Record – Notes
Nurse’s Notes Records the patient’s care throughout the day Includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition
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Common Elements of the Medical Record – Notes
Physician’s Progress Notes Daily record of patient’s condition Results of physical exam, summary of test results, updated assessment and diagnoses, further plans for treatment
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Common Elements of the Medical Record – Reports
Consultation Reports Given by a specialist when the physician asks for patient evaluation Ancillary Reports From various treatments and therapies Such as rehabilitation, social services, respiratory therapy, or dietetics
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Common Elements of the Medical Record – Reports
Operative Report From surgeon detailing the operation Includes pre- and post-operative diagnosis Specific details of the procedure and how the patient tolerated the procedure
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Common Elements of the Medical Record – Reports
Anesthesiologist’s Report Relates details of drugs given to patient Response to anesthesia Vital signs during surgery
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Common Elements of the Medical Record – Reports
Diagnostic Reports Results of all diagnostic tests performed on the patient From lab to medical imaging Pathologist’s Report Report given by pathologist who studies tissue removed from patient
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Common Elements of the Medical Record
Informed Consent Document voluntarily signed by the patient or responsible party Clearly describes purpose, methods, procedures, benefits, and risks of procedures
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Common Elements of the Medical Record
Discharge Summary Outline of patient’s entire hospital stay Includes condition at admission, admitting diagnosis, test results, treatments, and patient’s response, final diagnosis, and follow-up plans
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Healthcare Settings Acute Care or General Hospital
Provides services to diagnose and treat diseases for a short period of time Specialty Care Hospital Provides care for specific type of disease Example: psychiatric hospital
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Figure 1.3 A nurse and medical assistant review a patient’s chart and plan his or her daily care.
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Healthcare Settings Nursing Home or Long-Term Care Facility
Provides long-term care for patients who need extra time to recover before going home For persons who cannot care for themselves
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Healthcare Settings Ambulatory Care, Surgical Center, or Outpatient Clinic For patients who do not need overnight care Simple surgeries, therapy, or diagnostic testing
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Healthcare Settings Physician’s Office Health Maintenance Organization
Individual or group of doctors providing diagnostic and treatment services in an office setting Health Maintenance Organization Group of primary care physicians, specialists, and other healthcare professionals Provides wide range of services in a pre-paid system
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Healthcare Settings Home Health Care Rehabilitation
Agencies that provide nursing, therapy, personal care, or housekeeping services in patient’s home Rehabilitation Provides physical and occupational therapy Inpatient and outpatient
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Healthcare Settings Hospice
Organized group of health workers that provide supportive treatment to terminally ill patients and their families
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Confidentiality Any information or record relating to a patient is privileged Moral and legal responsibility to keep all information private Proper authorization must be signed by patient before any information can be released
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Confidentiality Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets federal standards to protect records
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Click on the screenshot to view a video describing HIPAA.
HIPAA Video Click on the screenshot to view a video describing HIPAA. Back to Directory
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Classroom Response System
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Pop Question 1 Which of the following is NOT one of the four basic word parts used to build medical terms? Prefix Combining root Suffix Word root
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Answer 1 Which of the following is NOT one of the four basic word parts used to build medical terms? Prefix Combining root Suffix Word root
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Pop Question 2 Which of the following combinations is used to make a combining form? Prefix + suffix Prefix + word root Word root + suffix Word root + combining vowel
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Answer 2 Which of the following combinations is used to make a combining form? Prefix + suffix Prefix + word root Word root + suffix Word root + combining vowel
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Pop Question 3 A combining vowel is NOT used: Between two word roots
When the suffix begins with a vowel When the suffix begins with a consonant Between a prefix and word root
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Answer 3 A combining vowel is NOT used: Between two word roots
When the suffix begins with a vowel When the suffix begins with a consonant Between a prefix and word root
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Pop Question 4 The combining form for skin is: Dermat/o Gastr/o
Cardi/o Nephr/o
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Answer 4 The combining form for skin is: Dermat/o Gastr/o Cardi/o
Nephr/o
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Pop Question 5 The combining form hemat/o means: Stomach
Small intestines Blood Nose
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Answer 5 The combining form hemat/o means: Stomach Small intestines
Blood Nose
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Pop Question 6 Which medical terminology word part gives information about location or time? Word root Prefix Combining form Suffix
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Answer 6 Which medical terminology word part gives information about location or time? Word root Prefix Combining form Suffix
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Pop Question 7 Which prefix means painful, difficult, or abnormal? Eu-
Anti- Dys- Retro-
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Answer 7 Which prefix means painful, difficult, or abnormal? Eu- Anti-
Dys- Retro-
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Pop Question 8 Which prefix means the opposite of brady-? Tachy- Pre-
Trans- Neo-
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Answer 8 Which prefix means the opposite of brady-? Tachy- Pre- Trans-
Neo-
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Pop Question 9 Which prefix means within or inside? Inter- Infra-
Intra- Infer-
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Answer 9 Which prefix means within or inside? Inter- Infra- Intra-
Infer-
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Pop Question 10 Which of the following is NOT information given by suffixes? Condition Disease Number Procedure
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Answer 10 Which of the following is NOT information given by suffixes?
Condition Disease Number Procedure
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Pop Question 11 Which suffix has the same meaning as -algia? -dynia
-cise -ectasis -malacia
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Answer 11 Which suffix has the same meaning as -algia? -dynia -cise
-ectasis -malacia
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Pop Question 12 What is the meaning of the suffix -stenosis? Enlarged
Hardening Narrowing Destruction
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Answer 12 What is the meaning of the suffix -stenosis? Enlarged
Hardening Narrowing Destruction
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Pop Question 13 Which surgical suffix means to remove? -ectomy -ostomy
-plasty -otomy
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Answer 13 Which surgical suffix means to remove? -ectomy -ostomy
-plasty -otomy
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Pop Question 14 Which of the procedural suffixes means an instrument for recording? -gram -scope -graph -metry
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Answer 14 Which of the procedural suffixes means an instrument for recording? -gram -scope -graph -metry
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Pop Question 15 The correct plural for the medical term thorax is:
Thoraxae Thoraxes Thoraces Thoraxia
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Answer 15 The correct plural for the medical term thorax is: Thoraxae
Thoraxes Thoraces Thoraxia
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Pop Question 16 The use of abbreviations in medical charts is usually discouraged. True False
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Answer 16 The use of abbreviations in medical charts is usually discouraged. True False
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Pop Question 17 Which part of a medical record is the physician’s daily record of the patient’s condition? History and Physical Consultation Report Physician’s Orders Physician’s Progress Note
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Answer 17 Which part of a medical record is the physician’s daily record of the patient’s condition? History and Physical Consultation Report Physician’s Orders Physician’s Progress Note
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Pop Question 18 What information is found in a Diagnostic Report?
Test results Details from an operation Rehabilitation progress Information from a pathologist
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Answer 18 What information is found in a Diagnostic Report?
Test results Details from an operation Rehabilitation progress Information from a pathologist
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Pop Question 19 Another name for an acute care hospital is a(n):
Surgical center General hospital Health maintenance organization Outpatient clinic
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Answer 19 Another name for an acute care hospital is a(n):
Surgical center General hospital Health maintenance organization Outpatient clinic
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Pop Question 20 Which healthcare setting specifically provides supportive treatment to terminal patients? Home healthcare Hospice Rehabilitation center Nursing home
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Answer 20 Which healthcare setting specifically provides supportive treatment to terminal patients? Home healthcare Hospice Rehabilitation center Nursing home
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