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Introduction to Medical Terminology

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Florida State College of Jacksonville, HSC 1531 Medical Terminology for Healthcare Professionals. Unit 1 - Introduction

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Introduction to Medical Terminology

  1. 1. Welcome to ……. <ul><li>HSC 1531 </li></ul><ul><li>Medical Terminology for Healthcare Professionals </li></ul><ul><li>Spring 2010 Session B 12 </li></ul><ul><li>Reference No. 318972 </li></ul><ul><li>Wednesdays 5:30pm – 9:10pm </li></ul><ul><li>Professor: Michael L. Whitchurch, MHS </li></ul>
  2. 2. Introduction to Medical Terminology Medical Terminology for Healthcare Professionals HSC 1531 Instructor: Michael L. Whitchurch, MHS, OT/L Florida State College of Jacksonville
  3. 3. Introduction to medical terminology <ul><li>Building medical terms from word parts </li></ul><ul><li>Singular and plural endings </li></ul><ul><li>Abbreviations </li></ul><ul><li>The medical record </li></ul><ul><li>Health care settings </li></ul><ul><li>Confidentiality </li></ul>
  4. 4. Medical Terminology at a Glance <ul><li>Studying medical terminology is like learning a new language </li></ul><ul><li>Basic rules for building terms will help you both build and translate many different words </li></ul><ul><li>You must be able to put words together or build words from their parts </li></ul><ul><ul><li>Like piecing together a puzzle </li></ul></ul>
  5. 5. Understanding Medical Terms <ul><li>It is impossible to memorize all of the thousands of medical terms </li></ul><ul><li>You can distinguish the meaning of many different words by analyzing the word parts </li></ul>
  6. 6. Principles of component parts <ul><li>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 . Many prefixes and suffixes have more than a single definition so one must learn to use the definition that best describes the term. </li></ul>
  7. 7. Fundamentals of word structure <ul><li>The fundamental elements in medical terminology </li></ul><ul><li>are ….. </li></ul><ul><li>the component parts used to build medical words </li></ul><ul><li>P = Prefix </li></ul><ul><li>R = Word Root </li></ul><ul><li>CF = Combining Form </li></ul><ul><li>S = Suffix </li></ul>
  8. 8. Principles of component parts <ul><li>Prefix (p)– means to fix before or to fix to the beginning of a word. A prefix is a syllable or a group of syllables placed at the beginning of a word to alter of modify the meaning of the word to create a new word. </li></ul><ul><li>Word Root (wr) – 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. </li></ul>
  9. 9. Principles of component parts <ul><li>Combining Form (cf) – a word root to which a vowel has been added to join the root to a second root or to a suffix. The vowel “o” is the most common vowel used to make combing forms. They are found at the beginning of a word or within a word. </li></ul><ul><li>Suffix (s) – means to fasten on beneath or under. A suffix may 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. </li></ul>
  10. 10. Principles of component parts <ul><li>Prefixes …. </li></ul><ul><li>with more than a single definition </li></ul><ul><li>that pertain to position or placement </li></ul><ul><li>that pertain to number and amount </li></ul><ul><li>that are descriptive and are used in general </li></ul><ul><li>Suffixes …. </li></ul><ul><li>that have more than a single meaning </li></ul><ul><li>that pertain to pathologic conditions </li></ul><ul><li>used in diagnostic and surgical procedures </li></ul><ul><li>that are descriptive and are used in general </li></ul>
  11. 11. Identifying medical words <ul><ul><ul><ul><ul><li>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. Spelling of all medical words is extremely important because the addition or omission of a single letter may change the meaning of the word. </li></ul></ul></ul></ul></ul>
  12. 12. Identifying medical words <ul><li>Spelling Guidelines : </li></ul><ul><li>… if the suffix begins with a vowel , drop the combining vowel from the combining form and add the suffix. </li></ul><ul><li>… if the suffix begins with a consonant , keep the combining vowel and add the suffix to the combining form. </li></ul><ul><li>… keep the combining vowel between two or more roots in a term. </li></ul>
  13. 13. <ul><li>Click here to view a movie introducing the parts of a medical term. </li></ul>Medical Term Elements Video
  14. 14. Medical Terms Are Built from Word Parts <ul><li>Word Part </li></ul><ul><li>Word root </li></ul><ul><li>Prefix </li></ul><ul><li>Suffix </li></ul><ul><li>Combining form </li></ul><ul><li>Example (Meaning) </li></ul><ul><li>cardi ogram (record of the heart ) </li></ul><ul><li>peri cardium ( around the heart) </li></ul><ul><li>card itis ( inflammation of heart) </li></ul><ul><li>cardi o my o pathy (heart muscle disease) </li></ul>
  15. 15. Word Root <ul><li>Foundation of the term </li></ul><ul><li>General meaning of word </li></ul><ul><li>Often gives body system or part </li></ul><ul><ul><li>cardi = heart </li></ul></ul><ul><li>Or may be an action </li></ul><ul><ul><li>cis = to cut </li></ul></ul>
  16. 16. Word root <ul><li>Greek Word </li></ul><ul><li>Kardia (heart) </li></ul><ul><li>Gaster (stomach) </li></ul><ul><li>Hepar (liver) </li></ul><ul><li>Nephros (kidney) </li></ul><ul><li>Osteon (bone) </li></ul><ul><li>Word Root </li></ul><ul><li>Cardi </li></ul><ul><li>Gastr </li></ul><ul><li>Hepat </li></ul><ul><li>Nephr </li></ul><ul><li>oste </li></ul>
  17. 17. Combining Vowels
  18. 18. Combining Vowels
  19. 19. Combining Vowels <ul><li>Make it possible to pronounce long terms </li></ul><ul><li>Usually an “o” </li></ul><ul><li>Combine two word parts: </li></ul><ul><ul><li>Between two word roots </li></ul></ul><ul><ul><li>Between word root and suffix </li></ul></ul>
  20. 20. Combining Vowel Rules <ul><li>Between word root and suffix </li></ul><ul><li>If the suffix begins with a vowel </li></ul><ul><ul><li>Do not use a combining vowel </li></ul></ul><ul><ul><li>Arthr itis , not arthr oi tis </li></ul></ul><ul><li>If the suffix begins with a consonant </li></ul><ul><ul><li>Use a combining vowel </li></ul></ul><ul><ul><li>Arthro s cope, not arthr s cope </li></ul></ul>
  21. 21. <ul><li>Combining vowel is typically kept between two word roots </li></ul><ul><li>Even if the second word root begins with a vowel </li></ul><ul><ul><li>gastr oe nteritis, not gastr e nteritis </li></ul></ul>Combining Vowel Rules
  22. 22. Combining Form <ul><li>Typically used to write word roots </li></ul><ul><li>Also use the word root/combining vowel format </li></ul><ul><li>Examples: </li></ul><ul><ul><li>cardi/o </li></ul></ul><ul><ul><li>arthr/o </li></ul></ul><ul><ul><li>gastr/o </li></ul></ul>
  23. 23. Common Combining Forms <ul><li>aden/o </li></ul><ul><ul><li>gland </li></ul></ul><ul><li>carcin/o </li></ul><ul><ul><li>cancer </li></ul></ul><ul><li>cardi/o </li></ul><ul><ul><li>heart </li></ul></ul><ul><li>chem/o </li></ul><ul><li>chemical </li></ul><ul><li>cis/o </li></ul><ul><li>to cut </li></ul><ul><li>dermat/o </li></ul><ul><li>skin </li></ul><ul><li>enter/o </li></ul><ul><li>small intestine </li></ul><ul><li>gastr/o </li></ul><ul><li>stomach </li></ul><ul><li>gynec/o </li></ul><ul><li>female </li></ul><ul><li>hemat/o </li></ul><ul><li>blood </li></ul><ul><li>hydr/o </li></ul><ul><li>water </li></ul>
  24. 24. Common Combining Forms <ul><li>immun/o </li></ul><ul><li>immune </li></ul><ul><li>laryng/o </li></ul><ul><li>voice box </li></ul><ul><li>morph/o </li></ul><ul><li>shape </li></ul><ul><li>nephr/o </li></ul><ul><li>kidney </li></ul><ul><li>neur/o </li></ul><ul><li>nerve </li></ul><ul><li>ophthalm/o </li></ul><ul><li>eye </li></ul><ul><li>ot/o </li></ul><ul><li>ear </li></ul><ul><li>path/o </li></ul><ul><li>disease </li></ul><ul><li>pulmon/o </li></ul><ul><li>lung </li></ul><ul><li>rhin/o </li></ul><ul><li>nose </li></ul><ul><li>ur/o </li></ul><ul><ul><li>urine , urinary system </li></ul></ul>
  25. 25. <ul><li>Added to the front of a term </li></ul><ul><li>May add meaning such as: </li></ul><ul><ul><li>location of organ sub – = below </li></ul></ul><ul><ul><li>number of parts mono – = one </li></ul></ul><ul><ul><li>time (frequency) post – = after </li></ul></ul>Prefix
  26. 26. <ul><li>Not all medical terms have a prefix </li></ul><ul><li>When written by itself, followed by a hyphen </li></ul><ul><ul><li>intra– </li></ul></ul><ul><ul><li>hyper– </li></ul></ul><ul><ul><li>multi– </li></ul></ul>Prefix
  27. 27. Common Prefixes <ul><li>a– </li></ul><ul><li>without, away from </li></ul><ul><li>an– </li></ul><ul><li>without </li></ul><ul><li>ante– </li></ul><ul><li>before, in front of </li></ul><ul><li>anti– </li></ul><ul><li>against </li></ul><ul><li>auto– </li></ul><ul><li>self </li></ul><ul><li>brady– </li></ul><ul><li>slow </li></ul><ul><li>dys– </li></ul><ul><li>painful, difficult </li></ul>
  28. 28. Common Prefixes <ul><li>endo– </li></ul><ul><li>within , inner </li></ul><ul><li>epi– </li></ul><ul><li>upon, over </li></ul><ul><li>eu– </li></ul><ul><li>normal, good </li></ul><ul><li>hetero– </li></ul><ul><li>different </li></ul><ul><li>homo– </li></ul><ul><li>same </li></ul><ul><li>hyper– </li></ul><ul><li>over, above </li></ul><ul><li>hypo– </li></ul><ul><li>under, below </li></ul>
  29. 29. Common Prefixes <ul><li>infra– </li></ul><ul><li>under , beneath , below </li></ul><ul><li>inter– </li></ul><ul><li>among , between </li></ul><ul><li>intra– </li></ul><ul><li>within , inside </li></ul><ul><li>macro– </li></ul><ul><li>large </li></ul><ul><li>micro– </li></ul><ul><li>small </li></ul><ul><li>neo– </li></ul><ul><li>new </li></ul><ul><li>pan– </li></ul><ul><li>all </li></ul>
  30. 30. Common Prefixes <ul><li>para– </li></ul><ul><li>beside , beyond , near </li></ul><ul><li>per– </li></ul><ul><li>through </li></ul><ul><li>peri– </li></ul><ul><li>around </li></ul><ul><li>post– </li></ul><ul><li>after </li></ul><ul><li>pre– </li></ul><ul><li>before , in front of </li></ul><ul><li>pseudo– </li></ul><ul><li>false </li></ul><ul><li>retro– </li></ul><ul><li>backward , behind </li></ul>
  31. 31. Common Prefixes <ul><li>sub– </li></ul><ul><li>below , under </li></ul><ul><li>super– </li></ul><ul><li>above , excess </li></ul><ul><li>supra– </li></ul><ul><li>above </li></ul><ul><li>tachy– </li></ul><ul><li>fast </li></ul><ul><li>trans– </li></ul><ul><li>through , across </li></ul><ul><li>ultra– </li></ul><ul><li>beyond , excess </li></ul>
  32. 32. Number Prefixes <ul><li>bi – two </li></ul><ul><li>hemi – half </li></ul><ul><li>mono – one </li></ul><ul><li>multi – many </li></ul><ul><li>nulli – none </li></ul><ul><li>poly – many </li></ul><ul><li>quad – four </li></ul><ul><li>semi – partial , half </li></ul><ul><li>tri – three </li></ul><ul><li>uni – one </li></ul>
  33. 33. Suffix <ul><li>Attached to the end of a term </li></ul><ul><li>Adds meaning such as: </li></ul><ul><ul><li>condition –algia = pain </li></ul></ul><ul><ul><li>disease –itis = inflammation </li></ul></ul><ul><ul><li>procedure –ectomy = surgical removal </li></ul></ul>Pg 6
  34. 34. Suffix <ul><li>All medical terms must have a suffix </li></ul><ul><ul><li>Only mandatory word part </li></ul></ul><ul><li>When written by itself, precede with a hyphen </li></ul><ul><ul><li>– logy </li></ul></ul><ul><ul><li>– sclerosis </li></ul></ul><ul><ul><li>– cyte </li></ul></ul>
  35. 35. Common Suffixes <ul><li>– algia </li></ul><ul><li>pain </li></ul><ul><li>– cele </li></ul><ul><li>hernia, protrusion </li></ul><ul><li>– cise </li></ul><ul><li>cut </li></ul><ul><li>– cyte </li></ul><ul><li>cell </li></ul><ul><li>– dynia </li></ul><ul><li>pain </li></ul><ul><li>– ectasis </li></ul><ul><li>dilatatio n </li></ul><ul><li>– gen </li></ul><ul><li>that which produces </li></ul><ul><li>– genesis </li></ul><ul><li>produces, generates </li></ul>
  36. 36. Common Suffixes <ul><li>– genic </li></ul><ul><li>producing </li></ul><ul><li>– ia </li></ul><ul><li>state, condition </li></ul><ul><li>– iasis </li></ul><ul><li>abnormal condition </li></ul><ul><li>– logy </li></ul><ul><li>study of </li></ul><ul><li>– ism </li></ul><ul><li>state of </li></ul><ul><li>– itis </li></ul><ul><li>inflammation </li></ul><ul><li>– logist </li></ul><ul><li>one who studies </li></ul><ul><li>– lysis </li></ul><ul><li>destruction </li></ul>
  37. 37. Common Suffixes <ul><li>– malacia </li></ul><ul><li>abnormal softening </li></ul><ul><li>– megaly </li></ul><ul><li>enlargement, large </li></ul><ul><li>– oma </li></ul><ul><li>tumor, mass </li></ul><ul><li>– osis </li></ul><ul><li>abnormal condition </li></ul><ul><li>– pathy </li></ul><ul><li>disease </li></ul><ul><li>– plasia </li></ul><ul><li>development, growth </li></ul><ul><li>– plasm </li></ul><ul><li>formation, development </li></ul><ul><li>– ptosis </li></ul><ul><li>drooping </li></ul>
  38. 38. Common Suffixes <ul><li>– rrhage </li></ul><ul><li>excessive , abnormal flow </li></ul><ul><li>– rrhea </li></ul><ul><li>discharge, flow </li></ul><ul><li>– rrhexis </li></ul><ul><li>rupture </li></ul><ul><li>– sclerosis </li></ul><ul><li>hardening </li></ul><ul><li>– stenosis </li></ul><ul><li>narrowing </li></ul><ul><li>– therapy </li></ul><ul><li>treatment </li></ul><ul><li>– trophy </li></ul><ul><li>nourishment, development </li></ul>
  39. 39. Adjective Suffixes Pg 7
  40. 40. Adjective Suffixes <ul><li>Suffix may be used to convert a word root into a complete word </li></ul><ul><li>Translation of these suffixes is pertaining to </li></ul><ul><li>New word can then be used to modify another word </li></ul><ul><ul><li>The part of speech that modifies a noun or other substantive by limiting, qualifying, or specifying and distinguished in English morphologically by one of several suffixes, such as -able, -ous, -er, and -est, or syntactically by position directly preceding a noun or nominal phrase. </li></ul></ul>
  41. 41. Adjective Suffix Example <ul><li>To state that a patient has an ulcer in his stomach: </li></ul><ul><ul><li>gastr/o = stomach </li></ul></ul><ul><ul><li>-ic = pertaining to </li></ul></ul><ul><ul><li>gastric = pertaining to the stomach </li></ul></ul><ul><ul><li>gastric ulcer = ulcer found in the stomach </li></ul></ul>
  42. 42. Adjective Suffixes <ul><li>– ac </li></ul><ul><li>– al </li></ul><ul><li>– an </li></ul><ul><li>– ar </li></ul><ul><li>– ary </li></ul><ul><li>– ior </li></ul><ul><li>– ory </li></ul><ul><li>– ose </li></ul><ul><li>– ous </li></ul><ul><li>– tic </li></ul><ul><li>– eal </li></ul><ul><li>– iac </li></ul><ul><li>– ic </li></ul><ul><li>– ical </li></ul><ul><li>– ile </li></ul>Pg 7
  43. 43. Surgical Suffixes Pg 7
  44. 44. Surgical Suffixes <ul><li>– centesis </li></ul><ul><li>puncture to withdraw fluid </li></ul><ul><li>– ectomy </li></ul><ul><li>surgical removal </li></ul><ul><li>– ostomy </li></ul><ul><li>surgically create an opening </li></ul><ul><li>– otomy </li></ul><ul><li>cutting into </li></ul><ul><li>– pexy </li></ul><ul><li>surgical fixation </li></ul><ul><li>– plasty </li></ul><ul><li>surgical repair </li></ul><ul><li>– rrhaphy </li></ul><ul><li>suture </li></ul>
  45. 45. Procedural Suffixes Pg 8
  46. 46. Procedural Suffixes <ul><li>– gram </li></ul><ul><li>record or picture </li></ul><ul><li>– graph </li></ul><ul><li>instrument for recording </li></ul><ul><li>– graphy </li></ul><ul><li>process of recording </li></ul><ul><li>– meter </li></ul><ul><li>instrument for measuring </li></ul><ul><li>– metry </li></ul><ul><li>process of measuring </li></ul><ul><li>– scope </li></ul><ul><li>instrument for viewing </li></ul><ul><li>– scopy </li></ul><ul><li>process of visually examining </li></ul>
  47. 47. Word Building <ul><li>Putting together several parts to form a variety of terms to convey the necessary information </li></ul><ul><li>Begins with knowing the meaning of the various word parts in order to select the correct ones </li></ul><ul><li>Always remember the rules regarding the location of each word part </li></ul>
  48. 48. Let’s dissect a word …… gastroenterology
  49. 49. Interpreting Medical Terms <ul><li>Term to be translated …. ( Dissected ) </li></ul><ul><ul><li>gastroenterology </li></ul></ul><ul><li>Divide the term into its word parts </li></ul><ul><ul><li>gastr / o / enter / o / logy </li></ul></ul>
  50. 50. Interpreting Medical Terms <ul><li>Define each word part </li></ul><ul><ul><li>gastr = stomach </li></ul></ul><ul><ul><li>o = combining vowel, no meaning </li></ul></ul><ul><ul><li>enter = small intestine </li></ul></ul><ul><ul><li>o = combining vowel, no meaning </li></ul></ul><ul><ul><li>– logy = study of </li></ul></ul><ul><li>Combine the meanings of the word parts </li></ul><ul><ul><li>study of the stomach and small intestine </li></ul></ul>
  51. 51. Pronunciation <ul><li>Mispronunciations </li></ul><ul><li>Artery - the study of fine paintings </li></ul><ul><li>Barium - what you do when CPR fails </li></ul><ul><li>Benign - what you are after you be eight </li></ul><ul><li>Coma - a punctuation mark </li></ul><ul><li>Morbid - a higher offer </li></ul><ul><li>Urine - opposite of you’re out </li></ul><ul><li>Tablet - a small table </li></ul>Pg 8
  52. 52. Pronunciation <ul><li>Will differ according to place of birth and education </li></ul><ul><li>When in doubt, ask for spelling </li></ul><ul><li>New terms in the book are introduced in boldface type, with phonetic spelling in parentheses </li></ul><ul><li>Stressed syllable will be in capital letters: </li></ul><ul><ul><li>pericarditis (per ih car DYE tis) </li></ul></ul>
  53. 53. Spelling <ul><li>Only one correct way to spell a term </li></ul><ul><li>Changing one letter can change the meaning of a word </li></ul><ul><ul><li>abduction </li></ul></ul><ul><ul><ul><li>(moving away) vs. adduction (moving towards) </li></ul></ul></ul><ul><ul><li>ileum </li></ul></ul><ul><ul><ul><li>(small intestine) vs. ilium (hip bone) </li></ul></ul></ul>Pg 9
  54. 54. Same Sounds Spelled Differently <ul><li>psy psychiatry </li></ul><ul><li>cy cytology </li></ul><ul><li>dys dyspepsia </li></ul><ul><li>dis dislocation </li></ul>
  55. 55. Singular and Plural Endings <ul><li>Many medical terms come from Greek or Latin words </li></ul><ul><li>Rules for forming plurals for these languages are different from English </li></ul><ul><ul><li>Plural of atrium is atria, not atriums </li></ul></ul><ul><li>Other words will use English rules </li></ul><ul><ul><li>Plural of ventricle is ventricles </li></ul></ul>Pg 9
  56. 56. General Rules for Plurals
  57. 57. General Rules for Plurals
  58. 58. General Rules for Plurals <ul><li>Word Ends In </li></ul><ul><li>– a </li></ul><ul><li>– ax </li></ul><ul><li>– ex or –ix </li></ul><ul><li>– is </li></ul><ul><li>– ma </li></ul><ul><li>– nx </li></ul><ul><li>– on </li></ul><ul><li>– us </li></ul><ul><li>– um </li></ul><ul><li>– y </li></ul><ul><li>Plural </li></ul><ul><li>vertebrae </li></ul><ul><li>thoraces </li></ul><ul><li>appendices </li></ul><ul><li>metastases </li></ul><ul><li>sarcomata </li></ul><ul><li>phalanges </li></ul><ul><li>ganglia </li></ul><ul><li>nuclei </li></ul><ul><li>ova </li></ul><ul><li>biopsies </li></ul><ul><li>Singular </li></ul><ul><li>vertebra </li></ul><ul><li>thorax </li></ul><ul><li>appendix </li></ul><ul><li>metastasis </li></ul><ul><li>sarcoma </li></ul><ul><li>phalanx </li></ul><ul><li>ganglion </li></ul><ul><li>nucleus </li></ul><ul><li>ovum </li></ul><ul><li>biopsy </li></ul>
  59. 59. Abbreviations <ul><li>Commonly used to save time </li></ul><ul><li>Can be confusing </li></ul><ul><li>If you are concerned about confusion, spell out the term </li></ul><ul><li>Do not use your own personal abbreviations </li></ul>Pg 10
  60. 60. The Medical Record <ul><li>Documents details of hospital stay </li></ul><ul><ul><li>Patient’s day-to-day condition </li></ul></ul><ul><ul><li>When and what services were provided </li></ul></ul><ul><ul><li>Response to treatment </li></ul></ul><ul><li>All personnel with patient contact complete the appropriate report </li></ul><ul><li>Medical records department ensures that all documents are present, complete, signed, and in order </li></ul>
  61. 61. Medical Transcriptionist Video Click here to view a video on the duties of the medical transcriptionist.
  62. 62. Common Elements of the Medical Record <ul><li>History and Physical </li></ul><ul><ul><li>Written by admitting physician </li></ul></ul><ul><ul><li>Details patient’s: </li></ul></ul><ul><ul><ul><li>History </li></ul></ul></ul><ul><ul><ul><li>Exam results </li></ul></ul></ul><ul><ul><ul><li>Initial diagnosis </li></ul></ul></ul><ul><ul><ul><li>Physician’s plan of treatment </li></ul></ul></ul><ul><li>Physician’s Orders </li></ul><ul><ul><li>Ordered by the doctor </li></ul></ul><ul><ul><li>Complete list of: </li></ul></ul><ul><ul><ul><li>Care </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Tests </li></ul></ul></ul><ul><ul><ul><li>Treatments </li></ul></ul></ul>
  63. 63. Patient Histories Video One Click here to view a video on the correct manner while taking patient histories.
  64. 64. Patient Histories Video Two Click here to view a video on the wrong manner while taking patient histories.
  65. 65. Common Elements of the Medical Record – Notes <ul><li>Nurse’s Notes </li></ul><ul><ul><li>Records the patient’s care throughout the day </li></ul></ul><ul><ul><li>Includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition </li></ul></ul><ul><li>Physician’s Progress Notes </li></ul><ul><ul><li>Daily record of patient’s condition </li></ul></ul><ul><ul><li>Results of physical exam, summary of test results, updated assessment and diagnoses, further plans for treatment </li></ul></ul>
  66. 66. Common Elements of the Medical Record – Reports <ul><li>Consultation Reports </li></ul><ul><ul><li>Given by a specialist when the physician asks for patient evaluation </li></ul></ul><ul><li>Ancillary Reports </li></ul><ul><ul><li>From various treatments and therapies </li></ul></ul><ul><ul><li>Such as rehabilitation, social services, respiratory therapy, or dietetics </li></ul></ul>
  67. 67. Common Elements of the Medical Record – Reports <ul><li>Operative Report </li></ul><ul><ul><li>From surgeon detailing the operation </li></ul></ul><ul><ul><li>Includes pre- and post-operative diagnosis </li></ul></ul><ul><ul><li>Specific details of the procedure and how the patient tolerated the procedure </li></ul></ul><ul><li>Anesthesiologist’s Report </li></ul><ul><ul><li>Relates details of drugs given to patient </li></ul></ul><ul><ul><li>Response to anesthesia </li></ul></ul><ul><ul><li>Vital signs during surgery </li></ul></ul>
  68. 68. Common Elements of the Medical Record – Reports <ul><li>Diagnostic Reports </li></ul><ul><ul><li>Results of all diagnostic tests performed on the patient </li></ul></ul><ul><ul><li>From lab to medical imaging </li></ul></ul><ul><li>Pathologist’s Report </li></ul><ul><ul><li>Report given by pathologist who studies tissue removed from patient </li></ul></ul>
  69. 69. Common Elements of the Medical Record <ul><li>Informed Consent </li></ul><ul><ul><li>Document voluntarily signed by the patient or responsible party </li></ul></ul><ul><ul><li>Clearly describes purpose, methods, procedures, benefits, and risks of procedures </li></ul></ul><ul><li>Discharge Summary </li></ul><ul><ul><li>Outline of patient’s entire hospital stay </li></ul></ul><ul><ul><li>Includes condition at admission, admitting diagnosis, test results, treatments, and patient’s response, final diagnosis, and follow-up plans </li></ul></ul>
  70. 70. Healthcare Settings <ul><li>Acute Care or General Hospital </li></ul><ul><ul><li>Provides services to diagnose and treat diseases for a short period of time </li></ul></ul><ul><li>Specialty Care Hospital </li></ul><ul><ul><li>Provides care for specific type of disease </li></ul></ul><ul><ul><li>Example: psychiatric hospital </li></ul></ul>
  71. 71. Healthcare Settings <ul><li>Nursing Home or Long-Term Care Facility </li></ul><ul><ul><li>Provides long-term care for patients who need extra time to recover before going home </li></ul></ul><ul><ul><li>For persons who cannot care for themselves </li></ul></ul><ul><li>Ambulatory Care, Surgical Center or Outpatient Clinic </li></ul><ul><ul><li>For patients who do not need overnight care </li></ul></ul><ul><ul><li>Simple surgeries, therapy, or diagnostic testing </li></ul></ul>
  72. 72. Healthcare Settings <ul><li>Physician’s Office </li></ul><ul><ul><li>Individual or group of doctors providing diagnostic and treatment services in an office setting </li></ul></ul><ul><li>Health Maintenance Organization </li></ul><ul><ul><li>Group of primary care physicians, specialists, and other healthcare professionals </li></ul></ul><ul><ul><li>Provides wide range of services in a pre-paid system </li></ul></ul>
  73. 73. Healthcare Settings <ul><li>Home Health Care </li></ul><ul><ul><li>Agencies that provide nursing, therapy, personal care, or housekeeping services in patient’s home </li></ul></ul><ul><li>Rehabilitation </li></ul><ul><ul><li>Provides physical and occupational therapy </li></ul></ul><ul><ul><li>Inpatient and outpatient </li></ul></ul><ul><li>Hospice </li></ul><ul><ul><li>Organized group of health workers that provide supportive treatment to terminally ill patients and their families </li></ul></ul>
  74. 74. Confidentiality <ul><li>Any information or record relating to a patient is privileged </li></ul><ul><li>Moral and legal responsibility to keep all information private </li></ul><ul><li>Proper authorization must be signed by patient before any information can be released </li></ul><ul><li>Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets federal standards to protect records </li></ul>
  75. 75. HIPAA Video - Confidentiality Click here to view a video describing HIPAA.
  76. 76. Introduction to Medical Terminology Medical Terminology for Healthcare Professionals HSC 1531 Instructor: Michael L. Whitchurch, MHS, OT/L Florida State College of Jacksonville

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