Chapter 1
Acronym
a word formed by the combining of initial letters or syllables and letters of a series of words or a compound; can be pronounced as a word
Root
a word or word element from which other words are formed; the foundation of the word
Combining Form
a word root to which a vowel has been added; links the root to the suffix of the word root to another root
Necrosis
abnormal condition of tissue death necr- death -osis- condition
ac
acute
Thermometer
am instrument used to measure degree of heat, especially the temperature of a person therm/o- hot, heat -meter- instrument to measure
Apathy
condition in which one lacks feeling and emotions and is indifferent
DOB
date of birth
Derm
dermatology
Topography
description of a body part n relation to the anatomic region in which it is located top/o- place -graphy- recording
Diagnosis
determination of the cause and nature of a disease, which is most often determined through the process of knowledge dia- through -gnosis- knowledge
Centrifuge
device used in a laboratory to separate solids from liquids centr/i- center -fuge- to flee
Dx
diagnosis
Pulmonary Disease
disease of the lungs Pulmonologist pulmon/o- lung -ary- pertaining to -ist- one who specializes
Orthopedic (Orth) Surgery
diseases and disorders involving locomotor structures of the body Orthopedist orth/o- straight ped- child -ic- pertaining to -ist- one who specializes
Infectious Disease
diseases caused by the growth of pathogenic microorganisms within the body
Allergy/Immunology
diseases of an allergic nature Allergist/Immunologist immun/o- immune -logy- study of -ist- one who specializes
Pediatrics (Peds)
diseases of children Pediatrician ped- child iatr- treatment -ic- pertaining to -ician- specialist, physician
Internal Medicine
diseases of internal origin not usually treated surgically Internist intern- within -al- pertaining to -ist- one who specializes
Hematology
diseases of the blood and blood-forming tissues Hematologist hemat/o- blood -logy- study of -ist- one who specializes
Proctology
diseases of the colon, rectum, and anus Proctologist proct/o- anus, rectum -logy- study of -ist- one who specializes
Otorhinolaryngology (ENT)
diseases of the ear, nose, and larynx Otorhinolaryngologist ot/o- ear rhin/o- nose laryng/o- larynx -logy- study of -ist- one who specializes
Ophthalmology
diseases of the eye Ophthalmologist ophthalm/o- eye -logy- study of -ist- one who specializes
Gynecology (GYN)
diseases of the female reproductive system Gynecologist gynec/o- female -logy- study of -ist- one who specializes
Cardiology
diseases of the heart, arteries, veins, and capillaries Cardiologist cardi/o- heart -logy- study of -ist- one who specializes
Nephrology
diseases of the kidney and urinary system Nephrologist nephr/o- kidney -logy- study of -ist- one who specializes
Psychiatry (Psych)
diseases of the mind Psychiatrist psych/o- mind iatr- treatment -ist- one who specializes
Neurology (Neuro)
diseases of the nervous system Neurologist neur/o- nerve -logy- study of -ist- one who specializes
Dermatology (Derm)
diseases of the skin Dermatologist dermat/o- skin -logy- study of -ist- one who specializes
Gastroenterology
diseases of the stomach and intestines Gastroenterologist gastr/o- stomach enter/o- intestine -logy- study of -ist- one who specializes
Urology
diseases of the urinary system Urologist ur/o- urination -logy- study of -ist- one who specializes
Endocrinology
diseses of the endocrine system (the glands and the hormones they secrete) Endocrinologist endo- upon crin/o- to secrete -logy- study of -ist- one who specializes
If the suffix begins with a vowel...
drop the combining vowel from the combining form and add the suffix.
ENT
ear, nose, throat (larynx)
EHR
electronic health record
Epidemiology
epidemic diseases Epidemiologist epi- upon demi/o- people -logy- study of -ist- one who specializes
FP
family practice
g
gram
GYN
gynecology
Ht
height
Hx
history
If the suffix begins with a consonant...
keep the combining vowel and add the suffix to the combining form.
kg
kilogram
L
liter
Prognosis
literally means a state of foreknowledge; prediction of the course of a disease and the recovery rate of the affected person pro- before -gnosis- knowledge
Malignant
literally means formation of a bad kind; growing worse, harmful, cancerous malign- bad kind -ant- forming
Rapport
relationship of understanding between two individuals, especially between patient and physician
R
respiration
Office for Civil Rights (OCR)
responsible for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties
Rheumatology
rheumatic diseases Rheumatologist rheumat/o- rheumatism -logy- study of -ist- one who secializes
R
root
Microscope
scientific instrument designed to view small objects micro- small -scope- instrument for examining
Microorganism
small living organisms that are not visible to the naked eye micro- small organ- organ -ism- condition
SS
social security
Illness
state of being sick
Gerontology
study of aspects of aging Gerontologist geront/o- old age -logy- study of -ist- one who specializes
Pathology (Path)
study of structural and functional changes in tissues and organs caused by diseases Pathologist path/o- disease -logy- study of -ist- one who specializes
Etiology
study of the cause(s) of disease eti/o- cause -logy- study of
Radiology
study of x-rays and other imaging modalities that use x-rays radi/o- ray, x-ray -logy- study of
SOAP
subjective objective assessment plan
Antidote
substance given to counteract poisons and their effects
S
suffix
Orthopedic
surgical prevention and repair of musculoskeletal dysfunctions
Paracentesis
surgical puncture of a body cavity for fluid removal para- beside -centesis- surgical puncture
Cardiovascular (CV)
surgical repair and correction of cardiovascular dysfunctions
Colon and Rectum
surgical repair and correction of colon and rectal dysfunctions
Neurologic
surgical repair and correction of neurologic dysfunctions
Thoracic
surgical repair and correction of organs within the rib cage
Trauma
surgical repair and correction of traumatic injuries
General
surgical repair and correction of various body parts and/or organs
Vascular
surgical repair and correction of vascular (vessels) dysfunctions
Cosmetic, Reconstructive, Plastic
surgical repair, reconstruction, revision, or change of the texture, configuration, or relationship of contiguous structures of any part of the human body
Maxillofacial
surgical treatment of diseases, injuries, and defects of the human mouth, face, and dental structures
T
temperature
TPR
temperature, pulse, respiration
Empathy
the ability to sense intellectually and emotionally the feelings of another person
Triage
a system of prioritizing and classifying patient injuries to determine priority of need and treatment
incision
process of cutting into in- in, into cis- to cut -ion- process
Excision
process of cutting out, surgical removal ex- out cis- to cut -ion- process
PHI
protected health information
Psych
psychiatry, psychology
P
pulse
The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule)
- A set of national standards for the protection of certain health information.
Medical records serves as the following:
- 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 - means by which the patient or insurance company can verify that services billed were actually provided
Medical records could influence...
- credit - admission to educational institutions - employment - a person's ability to get health insurance or the rates paid for coverage - loss of dignity & autonomy
Autoclave
An apparatus that sterilizes instruments and items using steam under pressure (15 pounds of pressure per square inch) to reach a heat of 250 degrees Fahrenheit to 254 degrees Fahrenheit for a specified time, such as 30 minutes for single wrapped items
Health Insurance Portability and Accountability Act (HIPPA)
- passed in 1996 - is a set of rules that doctors, hospitals, and other health care providers must follow to help ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy. - also requires 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.
General Components of a Medical Record
1. Patient Data- last name, first name, gender, date of birth (DOB), marital status, etc. 2. Medical History (Hx)- past and current patient history 3. Physical Examination (PE)- current head-to-toe assignment of physical condition 4. Consent Form- patient or legal guardian giving permission for treatment 5. Informed Consent Form- signed by patient or legal guardian that explains purpose, risks, & benefits of a procedure and serves as proof that the patient was properly informed before undergoing a procedure 6. Physician's Orders- record of prescribed care, medications, tests, and treatments for a given patient 7. Nurse's Notes- vital signs (temperature (T), pulse (P), respiration (R) [TPR] and blood pressure (BP) 8. Physician's Progress Notes- documents progress of patient 9. Consultation Reports- specialist's evaluation of patient 10. Ancillary/Miscellaneous Reports- chemotherapy, respiratory therapy, etc. reports 11.Diagnostic Tests/ Laboratory Reports- results of diagnostic & lab tests 12. Operative Report- documentation from surgeon detailing operation 13. Anesthesiology Report- documentation of detailed account of anesthesia during surgery, which drugs were used, dose and time given, etc. 14. Pathology Report- results of samples taken from patient such as bone marrow, blood, or tissue. 15. Discharge Summary (also called Clinical Resume, Clinical Summary, or Discharge Abstract)- outline of patient's hospital care, including date of admission, diagnosis, course of treatment and patient's response, results of tests, final diagnoses, follow-up plans, and date of discharge
ABMS
American Board of Medical Specialties
ambulatory
Condition of being able to walk, not confined to bed
Autonomy
Condition of being self-governed; to function independently auto- self nom- law -y- condition
Cachexia
Condition of ill health, malnutrition, and wasting; it may occur in chronic diseases such as cancer and pulmonary tuberculosis cac- bad -hexia- condition
FACP
Fellow of the American College of Physicians
FACS
Fellow of the American College of Surgeons
Terms describing diseases that affect the body's organs originate from
Greek words
HIPAA
Health Insurance Portability and Accountability Act of 1996
HHS
Health and Human Services
Father of Medicine
Hippocrates
Macron -
Indicated the long sound of the vowel
Schwa (upside down e)
Indicates the central vowel sound of most unstressed syllables
Breve (smile of smiley face)
Indicates the short sound of the vowel
Most of the terms for the body's organs originated from
Latin words
Malformation
Literally means a process of being badly shaped, deformed; a structural defect that fails to form normal shape and therefore can affect the function (cleft palate) mal- bad format- a shaping -ion- process
Adhesion
Literally means a process of being stuck together; an abdominal adhesion usually involves the intestines and is cause by inflammation or trauma; this type of adhesion may cause an intestinal obstruction and require surgery adhes- stuck to -ion- process
Centigrade (C)
Literally means having 100 steps or degrees; unit of temperature measurement (Celsius scale) with a boiling point at 100 degrees and a freezing point at 0 degrees; each degree of temperature change is 0.01 (1/100) of the scale centi- one hundred, one hundredth -grade- a step
Abscess
Localized collection of pus, which may occur in any part of the body
Diacritics
Marks placed over or under vowels to indicate the long or short sound of the vowel
Neuro
Neurology
OCR
Office for Civil Rights
Antipyretic
Pertaining to an agent that is used to lower an elevated body temperature (fever) anti- against pyret- fever -ic- pertaining to
Antitussive
Pertaining to an agent that works against coughing anti- against tuss- cough -ive- nature of, quality of
Axillary
Pertaining to the armpit axill- armpit -ary- pertaining to
SOAP
S- Subjective- describes the patient's current condition in narrative form and is information provided by the patient O- Objective- symptoms that can be observed, such as those that are seen, felt, smelled, heard, or measured by the health care provider. A- Assessment- interpretation of the subjective and objective findings P- Plan- includes management and treatment regimen for the patient
Acute
Sudden, sharp, severe; used to describe a disease that has a sudden onset, severe symptoms, and a short course
Biopsy
Surgical removal of a small piece of tissue for microscopic examination; used to determine a diagnosis of cancer or other disease processes in the body bi(o)- life -opsy- to view
Centimeter (cm)
Unit of measurement in the metric system; one hundredth of a meter centi- one hundred, one hundredth -meter- measure
Single accent '
Used to indicate stress on certain syllables; a single accent mark is called a Primary Accent and is used with the syllable that has the strongest stress (primary syllable)
Double Accent "
Used to indicate syllables that are stressed less than primary syllables; a double accent mark is called a Secondary Accent
Asepsis
Without decay; sterile, free from all living microorganisms a- without sepsis- decay
Eponym
a disease, structure, operation, or procedure named for the person who discovered or described it first
Malaise
a general feeling of discomfort, uneasiness; often felt by a patient who has a chronic disease
Syndrome
a group of signs and symptoms occurring together that characterize a specific disease or pathological condition syn- together, with -drome- that which runs together
Abbreviation
a process of shortening a word or phrase into appropriate letters
Electronic Health Record (EHR)
an electronic record of health-related information for an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff i.e.- patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, radiology images, age, weight, and billing information
Protected Health Information (PHI)
an individual's health information
Initialism
another type of abbreviation; formed by the initial letters of a series of words or a compound term, but it's not pronounced s a word
Anesthesiology
appropriate anesthesia for partial or complete loss of sensation Anesthesiologist an- without esthesi/o- feeling -logy- study of -ist- one who specializes
ax
axillary
Keep the combining vowel...
between two or more roots in a term.
Bx
biopsy
BP
blood pressure
CV
cardivascular
Family Practice (FP)
care of members of the family regardless of age and/or sex
Efferent
carrying impulses away from a center
Afferent
carrying impulses toward a center
C
centigrade, Celcius
cm
centimeter
A patient's medical record, electronic or paper, is often referred to as a...
chart or file
Disinfectant
chemical substance that can be applied to objects to destroy pathogenic microorganisms, such as bacteria dis- apart infect- to infect -ant- forming
CC
chief complaint
CF
combining form
Disease
literally means lack of ease; a pathological condition of the body that presents with a series of symptoms, signs, and laboratory findings peculiar to it and sets it apart from normal or other abnormal body states; a disruption of normal functioning of the body by a process that can be congenital, infectious, or the failure of normal activity and sustain health
Heterogeneous
literally means pertaining to a different formation; composed of unlike substances; the opposite of homogeneous hetero- different gene- formation, produce -ous- pertaining to
Oncology
literally means the study of tumors; the study of the etiology, the characteristics, treatments, etc., of cancer onc/o- tumor -logy- study of
Medical Record
may be written on paper or be digital; describes information about a patient and his or her health care; contains the dates, observations, medical or surgical interventions, and treatment outcomes provided during hospitalization or a visit to a health care facility; contains info that patient provides concerning symptoms and medical history, results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans
mcg
microgram
mg
milligram
mL, ml
milliliter
Neopathy
new disease neo- new -pathy- disease
OB
obstetrics
Multiform
occurring in or having many shapes; an object that has more than one defined shape multi- many, much -form- shape
Covered Entities
organizations subject to the Privacy Rule
Orth
orthopedics
Pallor
paleness, a lack of color
Path
pathology
Peds
pediatrics
Antiseptic
pertaining to an agent that woks against sepsis (putrefaction); a technique or product used to prevent or limit infections anti- against sept- putrefaction -ic- pertaining to
Abnormal
pertaining to away from the norm or rule; a condition that is considered to be not normal (ab-away from; norm-rule; -al-pertaining to)
Febrile
pertaining to fever, a sustained body temperature above 98.6 degrees Fahrenheit
Macroscopic
pertaining to objects large enough to be examined by the naked eye macr/o- large scop- to examine -ic- pertaining to
Prophylactic
pertaining to preventing or protecting against disease or pregnancy prophylact- guarding -ic- pertaining to
Maximal
pertaining to the greatest possible quantity, number, or degree maxim- greatest -al- pertaining to
Minimal
pertaining to the least possible quantity, number or degree minim- least -al- pertaining to
Palmar
pertaining to the palm of the hand palm- palm -ar- pertaining to
Pyrogenic
pertaining to the production of heat; a fever pyr/o- heat, fire -genic- formation, produce
Chronic
pertaining to time; denotes a disease with little change or of slow progression; the opposite of acute
Epidemic
pertaining to upon the people; the rapid, widespread occurrence of an infectious disease that can be spread by any pathological organism transmitted by and to humans, birds, insects, etc. epi- upon dem- people -ic- pertaining to
PE
physical examination
P
prefix
Bariatrics
prevention, control, and treatment of obesity Bariatrician bar- weight/pressure iatr- treatment -ic- pertaining to -ician- specialist, physician
In addition to info about physical health, medical records may include...
private and confidential information about: - family relationships - sexual behavior - substance abuse - personal thoughts and feelings
Surgery
the branch of medicine dealing with manual and operative procedures for correction of deformities and defects, repair of injuries, and diagnosis and cure of certain diseases
Medical Terminology
the study of terms that are used in the art and science of medicine; a specialized language with its origin arising for the Greek influence on medicine.
Chemotherapy
the use of chemical agents in the treatment of disease, specifically drugs used in cancer therapy chem/o- chemical -therapy- treatment
Diaphoresis
to carry through sweat glands; profuse sweating dia- through -phoresis- to carry
Suffix
to fasten on, beneath, or under; 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
Prefix
to fix before; to fix to the beginning; can be a syllable or a group of syllables
Abate
to lessen, ease, decrease, or cease; used to note the lessening of pain or the decrease in severity of symptons
Physical Medicine and Rehabilitation
treatment of disease by physical agents Physiatrist phys- nature iatr- treatment -ist- one who specializes
Obstetrics (OB)
treatment of the female during pregnancy, childbirth, and postpartum Obstetrician The Latin word element OBSTETRIX means midwife -ician- specialist, physician
Milliliter (mL, ml)
unit of volume in the metric system; 0.001 L milli- one-thousandth -liter- liter
Liter (L)
unit of volume in the metric system; 1000 mL; a liter is equal to 33.8 fl oz or 1.0567 qt
Milligram (mg)
unit of weight in the metric system; 0.001 g milli- one-thousandth -gram- a weight
kilogram (kg)
unit of weight in the metric system; 1000 g; a kilogram is equal to 2.2 lb
Gram (g)
unit of weight in the metric system; a cubic centimeter or a milliliter of water is equal to the weight of a gram
Microgram (mcg)
unit of weight in the metric system; one-millionth of a gram or one-thousandth of a milligram (0.001 mg) micro- small -gram- a weight
Wt
weight
y/o
year(s) old