1 Learning Outcomes Describe the fundamental elements that are used to build medical words List three guidelines for building and spelling medical words Explain the use of abbreviations when writing and documenting data ID: 643913
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Slide1
Introduction to Medical Terminology
1Slide2
Learning OutcomesDescribe the fundamental elements that are used to build medical words.
List three guidelines for building and spelling medical words.
Explain the use of abbreviations when writing and documenting data.Slide3
Learning OutcomesAnalyze, build, spell, and pronounce medical words.Identify and define selected abbreviations.
Describe selected medical and surgical specialties, giving the scope of practice and the physician’s title.Slide4
Learning OutcomesDefine HIPAA.List and describe the general components of a patient’s medical record.
List and describe the four parts of the SOAP Chart Note record.Slide5
Comprehension of Fundamental Word StructureMedical 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.Slide6
Fundamentals of Word StructureThe 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
.Slide7
PrefixPrefix 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.Slide8
Word RootA 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.Slide9
Combining FormA 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.Slide10
SuffixSuffix 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.Slide11
Principles of Component PartsAs 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.Slide12
Principles of Component PartsMost 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.Slide13
Identification of Medical Words
You will learn to distinguish among and select the appropriate component parts for the meaning of the word.Slide14
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.Slide15
SpellingSlide16
SpellingSlide17
SpellingSlide18
SpellingSlide19
SpellingSlide20
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.Slide21
a
as in
burs
a
to
ae
as in
burs
ae
ax
as in
thor
ax
to
aces
as in
thor
aces
or
es
as
in
thorax
es
en
as in
foram
en
to
ina
as in
foram
ina
is
as in
cris
is
to
es
as in
cris
es
Formation of Plural Endings
To change the following singular endings to plural endings, substitute the plural endings as illustrated:Slide22
To change the following singular endings to plural endings, substitute the plural endings as illustrated:
is
as in
ir
is
to
ides
as in
ir
ides
is
as in
femor
is
to
a
as in
femor
a
ix
as in
append
ix
to
ices
as in
append
ices
nx
as in
phala
nx
to
ges
as in
phalan
ges
Formation of Plural EndingsSlide23
To change the following singular endings to plural endings, substitute the plural endings as illustrated:
on
as in
spermatozo
on
to
a
as in
spermatozo
a
um
as in
ov
um
to
a
as in
ov
a
us
as in
nucle
us
to
i
as in
nucle
i
y
as in
arter
y
to
i
and add
es
as in
arter
ies
Formation of Plural EndingsSlide24
Use of AbbreviationsAn 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.Slide25
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.Slide26
PronunciationDiacritics 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 uncolored, central vowel sound of most unstressed syllables.Slide27
Audio Pronunciations
Abate
Abnormal
Abscess
Acute
AdhesionSlide28
Audio Pronunciations
Afferent
Ambulatory
Antidote
AntipyreticSlide29
Audio Pronunciations
Antiseptic
Antitussive
Apathy
AsepsisSlide30
Audio PronunciationsAutoclave
Autonomy
Axillary
Biopsy
CachexiaSlide31
Audio Pronunciations
Centigrade
Centimeter
Centrifuge
Chemotherapy
ChronicSlide32
Audio PronunciationsDiagnosis
Diaphoresis
Disease
DisinfectantSlide33
Audio Pronunciations
Efferent
Empathy
Epidemic
EtiologySlide34
Audio PronunciationsExcision
Febrile
Gram
Heterogeneous
IllnessSlide35
Audio Pronunciations
Incision
Kilogram
Liter
Macroscopic
MalaiseSlide36
Audio PronunciationsMalformation
Malignant
Maximal
MicrogramSlide37
Audio Pronunciations
Microorganism
Microscope
Milligram
MilliliterSlide38
Audio Pronunciations
Minimal
Multiform
Necrosis
Neopathy
OncologySlide39
Audio Pronunciations
Pallor
Palmar
Paracentesis
PrognosisSlide40
Audio Pronunciations
Prophylactic
Pyrogenic
Radiology
Rapport
SyndromeSlide41
Audio Pronunciations
Thermometer
Topography
TriageSlide42
Insert Table 1-1Slide43
Insert Table 1-1Slide44
Table 1.1 (continued)Selected Medical and Surgical SpecialtiesSlide45
Table 1.1 (continued)Selected Medical and Surgical SpecialtiesSlide46
Insert Table 1-1Slide47
Table 1.1 (continued)Selected Medical and Surgical SpecialtiesSlide48
Table 1.1 (continued)Selected Medical and Surgical SpecialtiesSlide49
Insert Table 1-1Slide50
Insert Table 1-2Slide51
The Medical RecordThe medical record is a written document of information describing a patient and his or her health care.
The record contains the dates, observations, medical or surgical interventions, and treatment outcomes provided during hospitalization or a visit to a doctor’s office.Slide52
The Medical RecordIt 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 health care provider, but the information in it belongs to the patient.Slide53
The Medical RecordBasis 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.Slide54
The Medical RecordMeans by which the patient or insurance company can verify that services billed were actually provided.Slide55
The Medical RecordHealth Insurance Portability and Accountability Act (HIPAA)
Set of rules passed in 1996 that must be followed by doctors, hospitals, and other health care providers to help ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy.Slide56
The Medical RecordHealth 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.Slide57
The Medical RecordTypes of Medical Records
Paper
Microfilm – photographs of records in a reduced size
Microfiche – sheets of microfilm
ElectronicSlide58
The Medical RecordPatient Information Form
A document that is filled out by the patient on the first visit to the physician’s office and then updated as necessary, providing data that relates directly to the patient.Slide59
The Medical RecordMedical History (Hx)
A document describing past and current history of all medical conditions experienced by the patient.Slide60
The Medical RecordPhysical 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.Slide61
The Medical RecordInformed 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.Slide62
The Medical RecordPhysician’s Orders
A record of the prescribed care, medications, tests, and treatments for a given patient.Slide63
The Medical RecordNurse’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.Slide64
Figure 1.1 Nurse’s NotesSlide65
The Medical RecordPhysician’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.Slide66
The Medical RecordConsultation 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.Slide67
The Medical RecordDiagnostic Tests/Laboratory Reports
Documents providing the results of all diagnostic and laboratory tests performed on the patient.Slide68
The Medical RecordOperative ReportDocumentation 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.Slide69
The Medical RecordAnesthesiology 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.Slide70
The Medical RecordPathology Report
Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue.Slide71
The Medical RecordDischarge Summary (also called Clinical Resum
é
, 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.Slide72
The Medical RecordSOAP (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.Slide73
The Medical RecordSOAP (Subjective, Objective, Assessment, Plan): Chart Note
Assessment
Interpretation of the subjective and objective findings.
Plan
Includes the management and treatment regimen for the patient.Slide74
AbbreviationsSlide75
Review QuizSlide76
The abbreviation for the Health Insurance Portability and Accountability Act is HIPPA.
True
FalseSlide77
The abbreviation for the Health Insurance Portability and Accountability Act is HIPPA.
True
FalseSlide78
The process of being stuck together is known as:
abate
abscess
adhesion
afferentSlide79
The process of being stuck together is known as:
abate
abscess
adhesion
afferentSlide80
A word element from which other words are formed is called:
combining vowel
prefix
suffix
word rootSlide81
A word element from which other words are formed is called:
combining vowel
prefix
suffix
word rootSlide82
Excision means the process of cutting out. The prefix ex- means:
out
to cut
process
inSlide83
Excision means the process of cutting out. The prefix ex- means:
out
to cut
process
inSlide84
The spreading process of cancer from one area of the body to another area is known as:
abnormal
efferent
malignant
neopathySlide85
The spreading process of cancer from one area of the body to another area is known as:
abnormal
efferent
malignant
neopathySlide86
Which branch of medicine is concerned with diseases of the kidney?
Family Practice
Internal Medicine
Nephrology
NeurologySlide87
Which branch of medicine is concerned with diseases of the kidney?
Family Practice
Internal Medicine
Nephrology
NeurologySlide88
Abate means to increase.
True
FalseSlide89
Abate means to increase.
True
FalseSlide90
The term for new disease
is neopathy.
True
FalseSlide91
The term for new disease
is neopathy.
True
FalseSlide92
A lack of color is called palmar.
True
FalseSlide93
A lack of color is called palmar.
True
FalseSlide94
The abbreviation for diagnosis
is Dx.
True
FalseSlide95
The abbreviation for diagnosis
is Dx.
True
FalseSlide96
An endocrinologist specializes in treating diseases of an allergic nature.
True
FalseSlide97
An endocrinologist specializes in treating diseases of an allergic nature.
True
FalseSlide98
The term prefix means to fix before or to fix to the end of a word.
True
FalseSlide99
The term prefix means to fix before or to fix to the end of a word.
True
FalseSlide100
Cachexia refers to a localized collection of pus.
True
FalseSlide101
Cachexia refers to a localized collection of pus.
True
FalseSlide102
Widespread occurrence of an infectious disease is called an epidemic.
True
FalseSlide103
Widespread occurrence of an infectious disease is called an epidemic.
True
FalseSlide104
The branch of medicine concerned with diseases of the lungs is pulmonary medicine.
True
FalseSlide105
The branch of medicine concerned with diseases of the lungs is pulmonary medicine.
True
FalseSlide106
A trauma surgeon would be responsible for medical repair of traumatic injuries.
True
FalseSlide107
A trauma surgeon would be responsible for medical repair of traumatic injuries.
True
FalseSlide108
ScenarioYou are currently working in a doctor’s office. Most of the people your doctor sees are overweight and are seeking help from your doctor. Slide109
What type of physician do you work for?
anesthesiologist
bariatrician
family practitioner
gastroenterologistSlide110
What type of physician do you work for?
anesthesiologist
bariatrician
family practitioner
gastroenterologistSlide111
What is not a primary concern
of bariatrics?
controlling obesity
preventing obesity
stopping obesity
treatment of obesitySlide112
What is not a primary concern
of bariatrics?
controlling obesity
preventing obesity
stopping obesity
treatment of obesitySlide113
The word root bar means
a bar
bar shaped
treatment
weight/pressureSlide114
The word root bar means
a bar
bar shaped
treatment
weight/pressureSlide115
In the word bariatrician, -ician is what word part?
combining form
prefix
suffix
word rootSlide116
In the word bariatrician, -ician is what word part?
combining form
prefix
suffix
word rootSlide117
In the word bariatrics, the word root iatr means:
physician
one who
weight/pressure
treatmentSlide118
In the word bariatrics, the word root iatr means:
physician
one who
weight/pressure
treatmentSlide119
Chapter 1 ScenarioThe following information was dictated by a cardiologist:
67 y/o Caucasian female c/o chest pain, shortness of breath, and dizziness
Patient appears apprehensive
Cyanotic around lips and mouth
Noted edematous abdomenSlide120
A cardiologist specializes in treating patients with diseases of the:
stomach and intestines
heart, arteries, veins, and capillaries
blood and blood-forming tissues
kidney and urinary systemsSlide121
A cardiologist specializes in treating patients with diseases of the:
stomach and intest
ines
heart, arteries, veins, and capillaries
blood and blood-forming tissues
kidney and urinary systems