Medical Terminology A LIVING LANGUAGE Fifth Edition CHAPTER
- Slides: 73
Medical Terminology A LIVING LANGUAGE Fifth Edition CHAPTER 1 Introduction to Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Multimedia Directory Slide 52 54 55 73 Medical Transcriptionist Video Patient Histories Video 1 Patient Histories Video 2 HIPAA Video Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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. Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Medical Terms Are Built from Word Parts Word Part Example (Meaning) • • Word root Prefix Suffix Combining form • cardiogram (record of the heart) • pericardium (around the heart) • carditis (inflammation of the heart) • cardiomyopathy (heart muscle disease) Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Combining Form • Typically used to write word roots • Also use the word root/combining vowel format • Examples: § cardi/o § arthr/o § gastr/o Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Combining Forms • • ot/o – ear path/o – disease pulmon/o – lung rhin/o – nose Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Prefix • Added to the front of a term • Adds meaning such as: § location of organ § number of parts § time (frequency) Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht sub- = below mono- = one post- = after
Prefix • Not all medical terms have a prefix • When written by itself, followed by a hyphen § intra§ hyper§ multi- Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Prefixes • • aananteantiautobradycontrade- without, away from without before, in front of against self slow against without Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Prefixes • • dysendoepiesoeuexexoextra- painful, difficult, abnormal within, inner upon, over inward normal, good external, outward outside of Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Prefixes • • heterohomohydrohyperhypoininterintra- different same water over, above under, below not, inward among, between within, inside Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Prefixes • • • macromicromyoneopanpara- • peri- large small to shut new all beside, near, abnormal, two like parts of a pair through around Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Prefixes • • postprepropseudoretrosubsupratachy- after before, in front of before false backward, behind below, under above fast Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Prefixes • trans • ultra • un- through, across beyond, excess not Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Number Prefixes • • • bihemimonomultinullipoly- two half one many none many • • • Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht primiquadrisemitetratri- first four partial, half four three
Suffix • Attached to the end of a term • Adds meaning such as: § condition -algia = pain § disease -itis = inflammation § procedure -ectomy = surgical removal Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Suffix • All medical terms must have a suffix § Only mandatory word part • When written by itself, precede with a hyphen § -logy § -sclerosis § -cyte Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Suffixes • • -algia -cele -cyte -dynia -ectasis -genesis -genic pain hernia, protrusion cell pain dilatation that which produces, generates producing, produced by Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Suffixes • • -iasis -iatry -ism -itis -logist -logy -lysis state, condition abnormal condition medical treatment state of inflammation one who studies study of destruction Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Suffixes • • -lytic -malacia -megaly -oid -oma -osis -pathy -phobia destruction abnormal softening enlargement, large resembling tumor, mass abnormal condition disease fear Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Suffixes • • -plasia -plasm -ptosis -rrhage -rrhagia -rrhexis -sclerosis development, growth formation, development drooping excessive, abnormal flow condition discharge, flow rupture hardening Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Suffixes • • -stenosis -therapy -trophy -ule narrowing treatment nourishment, development small Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Adjective Suffixes • • • -ac -al -an -ary -atic • • • -eal -iac -ile -ine -ior Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht • • • -nic -ory -ose -ous -tic
Surgical Suffixes • • -centesis -ectomy -ostomy -otomy -pexy -plasty -rrhaphy puncture to withdraw fluid surgical removal surgically create an opening cutting into surgical fixation surgical repair suture Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Procedural Suffixes • • -gram -graphy -meter -metry -scope -scopy record or picture instrument for recording process of recording instrument for measuring process of measuring instrument for viewing process of visually examining Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Word Building • For example: § 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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Interpreting Medical Terms • Term to be translated § gastroenterology • Divide the term into its word parts § gastr / o / enter / o / logy Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Interpreting Medical Terms • Define each word part § § § gastr = stomach o = combining vowel, no meaning enter = small intestine o = combining vowel, no meaning -logy = study of • Combine the meanings of the word parts § study of the stomach and small intestine Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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) Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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) Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Same Sounds Spelled Differently • Sounds like si § psy § cy psychiatry cytology • Sounds like dis § dys § dis dyspepsia dislocation Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Singular and Plural Endings • Many medical terms come from Greek or Latin words • Rules 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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht • Plural § § § § § vertebrae thoraces appendices metastases sarcomata phalanges ganglia ova nuclei biopsies
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Figure 1. 2 Health information professionals maintain accurate, orderly, and permanent patient records. Medical records are securely stored and available for future reference. Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
The Electronic Medical Record (EMR) • A software program • Allows entry of patient information into a computer Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Medical Transcriptionist Video Click on the screenshot to view a video on the duties of the medical transcriptionist. Back to Directory Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht • Physician’s Orders § Ordered by the doctor § Complete list of: • • Care Medications Tests Treatments
Patient Histories Video 1 Click on the screenshot to view a video on the correct manner while taking patient histories. Back to Directory Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Patient Histories Video 2 Click on the screenshot to view a video on the wrong manner while taking patient histories. Back to Directory Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Common Elements of the Medical Record – Reports • Anesthesiologist’s Report § Relates details of drugs given to patient § Response to anesthesia § Vital signs during surgery Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Figure 1. 3 A nurse and medical assistant review a patient’s chart and plan his or her daily care. Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Healthcare Settings • Ambulatory Care, Surgical Center, or Outpatient Clinic § For patients who do not need overnight care § Simple surgeries, therapy, or diagnostic testing Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Healthcare Settings • Physician’s Office § 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 prepaid system Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Healthcare Settings • Home Health Care § Agencies that provide nursing, therapy, personal care, or housekeeping services in patient’s home • Rehabilitation § Provides physical and occupational therapy § Inpatient and outpatient Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Healthcare Settings • Hospice § Organized group of health workers that provide supportive treatment to terminally ill patients and their families Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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 Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
Confidentiality • Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets federal standards to protect records Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
HIPAA Video Click on the screenshot to view a video describing HIPAA. Back to Directory Medical Terminology: A Living Language, Fifth Edition Bonnie F. Fremgen • Suzanne S. Frucht
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