Medical Terminology Module 1 PDF

Preview

Summary

Lesson 1: Introduction to Medical Terminology...

Description

RT 121: MEDICAL TERMINOLOGY LESSON 1: INTRODUCTION TO MEDICAL TERMINOLOGY LEARNING OBJECTIVES: 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 in medical terminology. 3. State the importance of correct spelling in medical terminology. 4. Explain the use of abbreviation when writing and documenting data. 5. Analyze, build, spell, and pronounce medical words. 6. Describe the purpose of medical coding and the ICD-10-CM, and identify the terminology related to it. 7. Understand the general components of a patient's medical record. 8. Apply your acquired knowledge of medical terminology by succesfully completing the practical application exercises.

WHAT IS MEDICAL TERMINOLOGY?

It is the study of terms that are used in the art and sciences of medicine. It is a specialized language with its origin arising from Greek influence on medicine. Because of the 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.

WHY IS MEDICAL TERMINOLOGY IMPORTANT?

Medical Terminology allows all medical professionals to understand each other and communicate effectively. When everyone understands what a condition, medicine, or procedure is, they are able to fulfill their roles accordingly. Medical Terminology creates a standardized language for medical professionals. By studying medical terminology, you will develop a fluency in the highly specialized language of health.

The fundamental elements in medical terminology are the component parts used to build medical words. FUNDAMENTALS OF WORD STRUCTURE

These elements are the: Prefix (P) Root word (R) Combining form (CF) Suffix (S)

The key to learning medical terminology is through word-building technique. Some medical terms are long, they often reduce an entire phrase to a single word. Example: Gastroduodenostomy - a communication between the stomach and the first part of the small intestine.

PREFIX

The term 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. prefixes are indicated by a dash after the prefix (pre-). Prefixes are used to: 1. alter or modify meaning of word/s 2. create an entirely new word.

A word root or word element from which other words are formed. It is the foundation of the word.

WORD ROOT

The root conveys the central meaning of the word and forms the base to which prefixes and suffixes are attached for word modification. Note that the same word root may have different meanings in different fields of study. Example: Scler means "hard" but may also apply to the white part of the eye.

SUFFIX

COMBINING FORM

Correct spelling is extremely important in medical terminology because of the addition or omission of a single letter can change the meaning of the word to something entirely different. Example:

PREFIXES AND SUFFIXES THAT ARE FREQUENTLY MISSPELLED

BUILDING AND SPELLING MEDICAL WORDS Follow these guidelines for building and spelling medical words.

FORMATION OF PLURAL ENDINGS To use medical terminology correctly, you must understand the plural and singular forms of words.

USE OF ABBREVIATIONS An abbreviation is a prcess of shortening a word or phrase into appropriate letters. It is used as a form of communication in writing and documenting data. The Institute for Safe Medication Practices (ISMP) and The Joint Commission (TJC) developed a list of abbreviations considered to be dangerous because of the potential misinterpretation. When using abbreviations, caution must be exercised. Many abbreviations have have multiple meanings, such as ER, whiich may mean Emergency room or Endoplasmic reticulum. Another example is the abbreviation is PA, which means either Physical assistant, posteroanterior, and pernicious anemia. It is essential that you use or translate the correct meaning for the abbreviation being used. If there is any question about which abbreviation to use, it is best to spell out the word or phrase and not use abbreviation.

ACRONYMS A word formed by combining the intial letters or syllables and letters, of a series of words or a compound term. Any shortened form of a word is an abbreviation, but an acronym is a special type of abbreviatio that can be pronounced as a word. Example: HIPPA (Health Insurance Portability and Accountability Act INITIALISM Another type of abbreviation that is formed by the initial letters of a series of words or compound term, but is not pronounced as a word instead each letter is pronounced. Example: DOB (Date of Birth)

EPONYM A name given to a medical disease, body part, or procedure derived from the name of the person who discovered or perfected ir. Often used in medical reports. Examples: Alzheimer disease - named after Alois Alzheimer, a neuropathologist who in 1906 identified an unusual disease of the cerebral cortex. PRONUNCIATION Pronunciatiion of medical words may seem difficult; however, it is very important to correctly pronounce medical words with the same or very similar sounds in order to convey their correct meanings. As in spelling, a mispronounced syllable can change the meaning of a medical word.

MEDICAL CODING It is the process of assigning alphanumeric characters that represent the diagnoses patients have been given and the services they are to receive. Alphanumeric refers to character set with alphabetic characters (A-Z) and numerals (0-9) Example: A69.21 = meningitis due to Lyme disease in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) A Philippine ICD-10 Modification is used in the Philippines. Diagnosis codes identify the reasons tha healthcare services were provided. Procedure codes describe the types of services, such as laboratory or radiology, and types of procedures, such as surgery, ordered for patients.

Worldwide, the present coding system, developed by the World Health Organization, is the International Classification of Diseases, 10th Revision (ICD-10), which was implemented for mortality coding and classification for feath certificates

MEDICAL RECORDS Electronic Health Record (EHR) is an electronic record of health-related information for an individual that is created, gathered, managed, and consulted by authorized healthcare clinicians and staff. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, radiology images, billing information. The EHR automates and streamlines the clinician's workflow. It has the ability to generate a complete record of a clinical patient encounter as well as supporting other care-related activities directly or indirectly via interface, including evidence-based decision support, quality management, and outcomes reporting. An EHR is generated and maintained within an institution, such as hospital, clinic, or physician's office. Its purpose is to give patients, physicians, and other healthcare providers, employers, or insurers access to a patient's medical records across facilities. Sections contained within the medical record may vary according to the physician's preference, type of practice, cost, and regulatory requirements. A patient's medical record (electronic pr paper) is often referred to as a chart or file. The general components of a patient;s medical record include the following: PATIENT DATA: Information that is provided by the patient and then updated as necessary. It is data that relates directly to the patient, including last name, first name, gender, date of birth, marital status, street address, city, state, zip code, telephone number, insurance information , employment status, address and phone number of employer, name and contact information for the person who is responsible for the patient's bill, and vital information for contact person in case of an emergency. MEDICAL HISTORY (Hx): Document describing past and current history of all medical conditions experienced by the patient. PHYSICAL EXAMINATION (PE): Record that includes a current head-to-toe assessment of the patient's physical condition. CONSENT FORM: Signed document by the patient or legal guardian giving permission or consent for treatment. INFORMED CONSENT FORM: Signed document by the patient or legal guardian that explains the purpose, risk, and benefits of a procedure and serves as a proof that the patient was properly informed before undergoing a procedure. PHYSICIAN'S ORDERS: Record of the prescribed care, medications, tests, and treatments for a given patient. NURSE'S NOTES: Record of a patient's care that includes vital signs, particularly temperature, pulse, respiration, and blood pressure. The nurse's notes can also include treatments, procedures, and patient's responses to such care. 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 (assessment and diagnosis [Dx]).

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. DIAGNOSTIC TESTS/LABORATORY RESULTS: Documents providing the results of all diagnostic and laboratory tests performed on the patient. OPERATIVE REPORT: Documentation from the surgeon detailing the operation, including the preoperative and postoperative diagnosis, specific details of the surgical procedure, and any complications that occurred. ANESTHESIOLOGY REPORT: Documentation from the attending anesthesiologist or nurse anesthetist 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. PATHOLOGY REPORT: Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissues. DISCHARGE OR SUMMARY: Also called Discharge abstract or Clinical summary. It is an outline summary of the patient's hospital care, including date of admission, diagnosis, course of treatment and patient's response(s), results of tests, final diagnosis, follow-up plans, and date of discharge.

SOAP: CHART NOTE The SOAP - subjective, objective, assessment, plan - chart note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as admission note. The SOAP note is a method is a method of displaying patient data in a concise, organized format and is written to improve communication among those caring for the patient. The length and focus of each component of a SOAP note varies depending on the specialty area. There are 4 parts of SOAP note chart: 1. Subjective - This describes the patient's condition in narrative form. It includes symptoms that the patient feels and describes to the healthcare professional. The healthcare professional can see the physical reaction of the patient but not the actual symptoms. Subjective symptoms can be verbally expressed by a patient. Also included in the subjective section is the patient's chief complaint (CC). This is the concern that brings the patient to a doctor. 2. Objective - Symptoms that can be observed, such as those that are seen, felt, smelled, heard, or measured by the healthcare provider. 3. Assessment - Interpretation of the subjective and objective findings. Generally includes a diganosis, including a differential diagnosis, or in some cases will rule out a disease/condition. 4. Plan - Includes the management and treatment regimen for the patient; may includel laboratory tests, radiological tests, physical therapy, dirt therapy, medications, medical and surgical interventions, patient referrals such as counseling and finding a support group, patient teaching, and follow-up directions. A SOAP chart note should express current patient data, including the date of the visit, patient's name, date of birth, age, and gender.

WORK SHEET 1 Section: PART 1: STUDY AND REVIEW WORD PARTS: Give the definitions of the prefixes, word roots, combining forms, and suffixes. Use the Building your medical vocabulary table or a medical dictionary.

PREFIXES 1. a2. ab3. anti4. cac5. centi6. dia-

7. hetero8. mal9. micro10. mill11. multi12. para-

13. pro14. syn15. dis16. epi17. ex18. in-

ROOTS AND COMBINING FORMS 1. adhes2. axill3. centr/i4. chem/o5. format6. gene7. kil/o8. macr/o9. necr10. norm11. onc/o12. organ13. pyr14. pyr/o-

15. radi/o16. scop17. sept18. therm/o19. tuss20. infect21. dem22. eti/o23. cis24. malign25. maxim26. minim27. palm28. prophylact-

SUFFIXES 1. -al 2. -art 3. -centesis 4. -drome 5. -form 6. -genic 7. -gnosis 8. -grade 9. -gram 10. -hexia 11. -ic 12. -ion

13. -ism 14. -ive 15. -liter 16. -logy 17. -meter 18. -osis 19. -ous 20. -phoresis 21. -scope 22. -sepsis 23. -theraphy 24. -ar

Part II: IDENTIFYING MEDICAL TERMS In the spaces provided, write the medical terns for the following meanings.

1. ______________________________________ Process of being stuck together 2. ______________________________________ Without decay 3. ______________________________________ Pertaining to the armpit 4. ______________________________________ Use of chemical agents in the treatment of disease 5. ______________________________________ Pertaining to a different formation 6. ______________________________________ Process of being badly shaped, deformed 7. ______________________________________ Scientific instrument designed to view small objects 8. ______________________________________ Occuring in or having many shapes 9. ______________________________________ Study of tumors PART III: ABBREVIATIONS Place the correct word, phrase, or abbreviation in the space provided. 1. CC __________________________________ 2. ax ___________________________________ 3. biopsy _______________________________ 4. weight _______________________________ 5. Neuro ________________________________ 6. ear, nose, throat ______________________ 7. dermatology _________________________ 8. gram ________________________________ 9. GYN _________________________________ 10. Orth ________________________________

PART IV: MATCHING Select the appropriate lettered meaning for each of the following. Write the letter on the space provided. _________ 1. HIPPA _________ 2. WHO _________ 3. CM _________ 4. PCS _________ 5. ICD _________ 6. CMS _________ 7. CPT _________ 8. A-Z _________ 9. OP _________ 10. CDC

a. clinical modification b. Procedure Coding System c. Health Insurance and Portability and Accountability Act d. Centers for Medical & Medicaid Services e. World Health Organization f. alphabetic characters g. Centers for Disease Control and Prevention h. outpatient i. International Classification of Diseases j. Current Procedural Terminology

BUILDING YOUR MEDICAL VOCABULARY This section provides the foundation for learning medical terminology. Review the following alphabetized word list. Note how common prefixes and suffixes are repeatedly applied to word roots and combining forms to create different meanings. The word parts are color coded: prefixes are yellow, suffixes are blue, and word roots or combing forms are red. These are common words or specialized terms that are included to enhance your medical vocabulary....