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Medical Terminology
             for Healthcare Professionals




                                                               The Structure of
                                                               Medical Language



Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Learning Objectives
1.   Identify the five skills of medical language communication.
2.   Describe the origins of medical language.
3.   Recognize common Latin and Greek singular nouns and form their plurals.
4.   Describe characteristics of combining forms, suffixes, and prefixes.
5.   Give the medical meaning of common word parts.
6.   Build medical words from word parts and divide medical words into word parts.
1.   Spell and pronounce common medical words. Describe the format and
     contents of common medical documents.
2.   Dive deeper into the structure of medical language by reviewing the activities
     at the end of this chapter and online at Medical Terminology Interactive.




     Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Welcome to Medical Language!

Medical language is the language of
   the healthcare profession, and
 medical words are the tools of the
trade. Learning medical language is
your key to a successful career in
        the healthcare field.




 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Language and
               Communication
Communication in any language consists of five
 language skills. These same five language skills
 are important in medical language:

 Reading
 Listening
 Thinking, analyzing, and understanding
 Writing (or typing) and spelling
 Speaking and pronouncing


   Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Beginning of Medical Language
 Etymology
 is the study of word origins and derivations.

 •   Many words have been derived from other languages.
 •   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.
                      Greek




     Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Beginning of Medical Language

• Some medical words are identical to Latin or Greek words.
• Some medical words are similar (but not identical)
  to Latin or Greek words.
• Some medical words are similar to words from
  old English, Dutch, and French.




    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Beginning of Medical Language


        Medical Word                                 Language of Origin
      nucleus                          Latin nucleus
      pelvis                           Latin pelvis
      sinus                            Latin sinus
      paranoia                         Greek paranoia
      thorax                           Greek thorax




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Beginning of Medical Language


         Medical Word                                 Language of Origin
      artery                            Latin arteria
      muscle                            Latin musculus
      vein                              Latin vena
      phobia                            Greek phobos

      sperm                             Greek sperma




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Beginning of Medical Language


   Medical Word                                  Language of Origin

 bladder                           English blaedre

 heart                             English heorte

 drug                              Dutch droog

 physician                         French physicien




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Singular and Plural Nouns

Many medical terms come from
Greek or Latin words

Rules for 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




    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Singular and Plural Nouns
Latin
        Singular                 How to Form the                                     Example
        Ending                        Plural
              -a                   Change -a to -ae                         vertebra → vertebrae

             -us                    Change -us to -i                         bronchus → bronchi

            -um                   Change -um to -a                          bacterium → bacteria

              -is                  Change -is to -es                               testis → testes

                                 Change -ex to -ices                               apex → apices
          -ex, -ix
                                 Change -ix to -ices                               helix → helices


   Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS            Copyright ©2011 All rights reserved.
Medical Singular and Plural Nouns
Greek

        Singular                     How to Form the                                  Example
        Ending                            Plural

              -is                     Change -is to -ides                             iris → irides


              -nx                    Change -nx to -nges                      phalanx → phalanges


            -oma                  Change -oma to -omata                           fibroma → fibromata


              -on                       Change -on to -a                          ganglion → ganglia



  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS              Copyright ©2011 All rights reserved.
Medical Words and Word Parts

• Medical language contains medical
  words.
• Most medical words contain word parts.
• Word parts are puzzle pieces that, when
  fit together, build a medical word.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Words and Word Parts
           (con't)
• There are three different kinds of word
  parts.
   – Combining forms
   – Suffixes
   – Prefixes




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Words and Word Parts
           (con’t)
               Word Part                                              Meaning

          combining form                            the foundation of the word

                    suffix                                     the word ending

                    prefix                         an optional word beginning




 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Figure 1-3 Combining form

Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Word Parts

• Characteristics of a Combining Form
    The foundation of a word
    Gives the word its main medical meaning.
    Has a root, a forward slash, a combining vowel, and a
     final hyphen.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Word Parts
                 combining vowel




Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Medical Word Parts (con't)

• Characteristics of a Combining Form
   – Most medical words contain a combining form.
   – Sometimes a medical word contains two or
     more combining forms, one right after the
     other.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Common Combining Forms

        Combining Form                                        Medical Meaning
                 abdomin/o-                                           abdomen
                 append/o-                                            appendix
                    arteri/o-                                           artery
                  intestin/o-                                         intestine
                   laryng/o-                                     larynx (voice box)
                  muscul/o-                                            muscle
                  thyroid/o-                                        thyroid gland
                   tonsill/o-                                           tonsil
                     veno-                                               vein


Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS    Copyright ©2011 All rights reserved.
Common Combining Forms

        Combining Form                                        Medical Meaning
                   arthr/o-                                                joint
                   cardi/o-                                                heart
                  derm/o-                                                  skin
                  gastr/o-                                               stomach
                  mamm/o-                                                 breast
                    nas/o-                                                 nose
                  psych/o-                                                 mind




Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS      Copyright ©2011 All rights reserved.
Common Combining Forms


        Combining Form                                        Medical Meaning
                cholecyst/o-                                           gallbladder
                   cost/o-                                                   rib
                  enter/o-                                              intestine
                  hepat/o-                                                 liver
                 hyster/o-                                               uterus
                  lapar/o-                                              abdomen




Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS        Copyright ©2011 All rights reserved.
Medical Word Parts: Suffixes
• Characteristics of a Suffix
   – A suffix is a word part that is at the end of a
     word.
   – A suffix modifies or clarifies the medical
     meaning of the combining form.
   – A suffix is a single letter or group of letters that
     begins with a hyphen.
   – Most medical words contain a suffix.


  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Figure 1-4 Suffix.

Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Suffixes for Adjective Forms




Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Suffixes for Adjective Forms


Suffix                 Medical Meaning                                 Example and Definition
 -ac                           pertaining to                          cardiac (pertaining to the heart)
                                                                          intestinal (pertaining to the
 -al                           pertaining to                                       intestine)
                                                                          muscular (pertaining to the
 -ar                           pertaining to
                                                                                  muscle)

 -ary                          pertaining to                             urinary (pertaining the urine)




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS        Copyright ©2011 All rights reserved.
Suffixes for Adjective Forms


Suffix                 Medical Meaning                                 Example and Definition

  -ic                          pertaining to                          pelvic (pertaining to the pelvis)

                                                                            uterine (pertaining to the
 -ine                          pertaining to                                         uterus)
                                                                              digestive (pertaining to
 -ive                          pertaining to                                         digestion)
 -ous                          pertaining to                           venous (pertaining to the vein)




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS         Copyright ©2011 All rights reserved.
Suffixes for Processes


Suffix Medical Meaning                                           Example and Definition
                  a process; being or
-ation                                                        urination (a process of [making] urine)
                        having
 -ion               action; condition                       digestion (action of breaking down food)
                  process of breaking                       hemolysis (process of breaking down or
 -lysis           down or destroying                                   destroying blood)




    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS    Copyright ©2011 All rights reserved.
Suffixes for Diseases
                  and Conditions

Suffix Medical Meaning                                           Example and Definition
  -ia           condition; state; thing                          pneumonia (condition of the lung)
              process; disease from a                      hypothyroidism (disease from the specific
 -ism
                  specific cause                              cause of deficient thyroid hormone)
             inflammation of; infection
 -itis                                                          tonsillitis (inflammation of the tonsil)
                        of
-megaly                enlargement                          cardiomegaly (enlargement of the heart)
 -oma                  tumor; mass                                   neuroma (tumor of the nerve)
                  condition; abnormal
 -osis                                                    psychosis (abnormal condition of the mind)
                   condition; process
-pathy             disease, suffering                             arthropathy (disease of the joint)



    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS       Copyright ©2011 All rights reserved.
Suffixes for Diagnostic, Medical, and
        Surgical Procedures




 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Suffixes for Diagnostic, Medical, and
        Surgical Procedures

Suffix               Medical Meaning                                 Example and Definition
                                                                  appendectomy (surgical excision
-ectomy                  surgical excision                               of the appendix)
                                                                  mammogram (a record or picture
-gram                  a record or picture                                the breast)
                                                                        mammography (process of
-graphy              process of recording                                 recording the breast)
                                                                  spirometry (process of measuring
-metry              process of measuring                                     the breath)
                       instrument used to                         colonoscope (instrument used to
-scope                       examine                                    examine the colon)


  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS    Copyright ©2011 All rights reserved.
Suffixes for Diagnostic, Medical, and
     Surgical Procedures (con't)


Suffix               Medical Meaning                                 Example and Definition
                                                                  gastroscopy (process of using an
                      process of using an
-scopy                                                               instrument to examine the
                    instrument to examine
                                                                             stomach)
                        surgically created                        colostomy (surgically creating an
-stomy                       opening                                    opening in the colon)
-therapy                   treatment                             psychiatry (treatment of the mind)
                      process of cutting or                      laparotomy (process of making an
 -tomy                 making an incision                             incision in the abdomen)



  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Suffixes for Medical Specialties



Suffix               Medical Meaning                                 Example and Definition
                                                                  psychiatry (medical treatment for
-iatry                  medical treatment                                     the mind)
                                                                  therapist (one who specializes in
 -ist               one who specializes in
                                                                               therapy)
 -logy                       the study of                         cardiology (the study of the heart)




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS    Copyright ©2011 All rights reserved.
Medical Word Parts: Prefixes

• Characteristics of a Prefix
   – A prefix is a word part that, if present, is at the
     beginning of a word.
   – A prefix modifies or clarifies the medical
     meaning of the combining form.
   – A prefix is a single letter or group of letters
     that ends with a hyphen.
   – Occasionally, a medical word has two
     prefixes.

  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Figure 1-5 Prefix

Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Prefixes for Location or Direction


 Prefix                 Medical Meaning                                 Example and Definition
                                                                           endotracheal (pertaining to
  endo-                     innermost; within                                 within the trachea)
                                                                         epidermal (pertaining to upon
  epi-                          upon; above                                        the skin)
                                                                             intercostal (pertaining to
  inter-                           between                                       between the ribs)
                                                                            intravenous (pertaining to
  intra-                              within                                       within a vein)




   Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS        Copyright ©2011 All rights reserved.
Prefixes for Location or Direction

 Prefix                 Medical Meaning                                 Example and Definition
                                                                             pericardial (pertaining to
  peri-                              around                                     around the heart)
                                                                       postnasal (pertaining to behind
  post-                         after; behind                                     the nose)
                                                                           premenstrual (pertaining to
  pre-                      before; in front of                               before menstruation)
                      below; underneath; less                             subcutaneous (pertaining to
  sub-                         than                                          underneath the skin)
                                                                            transvaginal (pertaining to
  trans-                     across; through                                    through the vagina)


   Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS        Copyright ©2011 All rights reserved.
Prefixes for Amount,
               Number, or Speed

Prefix               Medical Meaning                                 Example and Definition
 bi-                                 two                           bilateral (pertaining to two sides)
                                                                   bradycardia (condition of a slow
brady-                              slow                                          heart)
                                                                   hemiplegia (condition of one half
hemi-                            one half                            [of the body] with paralysis)
                                                                    hypertension (condition of more
hyper-           above; more than normal                                than normal pressure)




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS     Copyright ©2011 All rights reserved.
Prefixes for Amount,
               Number, or Speed
Prefix                 Medical Meaning                                 Example and Definition
                                                                      hypothyroidism (disease from a
hypo-                       below; deficient                            specific cause of deficient
                                                                         thyroid gland [hormone])
                                                                          mononucleosis (abnormal
                                                                        condition of [white blood cells
mono-                           one; single
                                                                         that each have] one [large]
                                                                                   nucleus)
                                                                         polyneuritis (inflammation of
 poly-                         many; much
                                                                               many nerves)
                                                                       quadriplegia (condition of four
quadri-                                four
                                                                          [limbs] with paralysis)


  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS       Copyright ©2011 All rights reserved.
Prefixes for Amount,
               Number, or Speed


Prefix                 Medical Meaning                                 Example and Definition
                                                                       tachycardia (condition of a fast
tachy-                                 fast                                        heart)
                                                                        trigeminal (pertaining to three
 tri-                                three                               [nerve branches in a] group)




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS       Copyright ©2011 All rights reserved.
Prefixes for Degree or Quality

Prefix              Medical Meaning                                   Example and Definition
                                                                             Aspermia
  a-                 away from; without
                                                                (condition [of being] without sperm)
                                                                            anesthesia
 an-                       without; not
                                                             (condition [of being] without sensation)
                                                                             antibiotic
 anti-                        against
                                                             (pertaining to against living organisms)
                                                                              dementia
 de-                 reversal of; without
                                                                (condition [of being] without a mind)




 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS      Copyright ©2011 All rights reserved.
Prefixes for Degree or Quality
Prefix         Medical Meaning                                       Example and Definition
                                                                               dysphagia
 dys-      painful; difficult; abnormal                                  (condition of painful or
                                                                    difficult eating and swallowing)
                                                                        euthyroidism
 eu-                 normal; good
                                                         (process of normal thyroid gland [function])
                                                                         Malnutrition
 mal-              bad; inadequate
                                                          (being or having inadequate nourishment)
                                                                          respiration
 re-               again and again
                                                           (a process of again and again breathing)




    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS      Copyright ©2011 All rights reserved.
Analyze and Define Words:
            Combining Form and Suffix
• Divide the medical word into its combining form
  and suffix.
• Define each word part.
• Put the word part meanings in this order:
  meaning of the suffix first, followed by the
  meaning of the combining form.
• Add small connecting words, if needed, to make
  a correct and complete definition of the medical
  word.

  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Analyze and Define Words:
Combining Form, Suffix and Prefix
• Divide the medical word into its prefix, combining
  form and suffix.
• Define each word part.

  Let’s dissect a word ……

                                       lo gy
                          nt ero
             st roe
       ga

  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Analyze and Define Words: Combining
       Form, Suffix and Prefix
• Put the word part meanings in this order:
  meaning of the suffix first, followed by the
  meaning of the prefix, followed by the
  meaning of the combining form.
• Add small connecting words, if needed, to
  make a correct and complete definition of
  the medical word.



  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Building Medical Words: Suffix that
     Begins with a Consonant
 • Select the suffix and combining form
   whose meanings match the definition of
   the medical word.
 • Change the order of the word parts to put
   the suffix last.
 • Delete the forward slash and hyphen from
   the combining form. Delete the hyphen
   from the suffix.
 • Join the two word parts.
   Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Building Medical Words: Suffix that
     Begins with a Consonant


   Medical Word                            Word Part                    Word Part Meaning
                                          combining form
           cardiology                                                                heart
                                             cardi/o-

                                             suffix -logy                         the study of




      Medical Word Definition                                  the study of the heart


  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS         Copyright ©2011 All rights reserved.
Building Medical Words: Suffix that
       Begins with a Vowel
 • Select the suffix and combining form
   whose meanings match the definition of
   the medical word.
 • Change the order of the word parts to put
   the suffix last.
 • Delete the forward slash, combining
   vowel, and hyphen from the combining
   form. Delete the hyphen from the suffix.
 • Join the two word parts.
   Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Building Medical Words: Suffix that
       Begins with a Vowel

   Medical Word                            Word Part                    Word Part Meaning
                                          combining form
             cardiac                                                                 heart
                                             cardi/o-

                                               suffix -ac                         pertaining to




     Medical Word Definition                                  pertaining to the heart


  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS          Copyright ©2011 All rights reserved.
Building Medical Words:
           Contains a Prefix
• Select the suffix, prefix and combining
  form whose meanings match the definition
  of the medical word.
• Change the order of the word parts to put
  the suffix last.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Building Medical Words:
            Contains a Prefix
• Delete the hyphen from the prefix. Delete
  the forward slash, combining vowel, and
  hyphen from the combining form. Delete
  the hyphen from the suffix.
• Join the three word parts.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Building Medical Words:
               Contains a Prefix

   Medical Word                            Word Part                    Word Part Meaning
                                          combining form
          intracardiac                                                               heart
                                             cardi/o-
                                              suffix -ac                          pertaining to
                                             prefix intra-                           within




Medical Word Definition                              pertaining to within the heart


  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS          Copyright ©2011 All rights reserved.
Pronounce Medical Words

• Knowing the definition of a medical word is
  important.
• Being able to pronounce the medical word
  correctly is equally important.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Pronounce Medical Words

• Follow these simple directions for
  pronouncing medical words:
   – Say each syllable by following the “see-and-
     say” pronunciation guide.
   – Accented syllables are in all capital letters.
   – Secondary accented syllables are in smaller
     capital letters.
   – Practice pronouncing the word several times
     until you have mastered its pronunciation.
  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Pronounce Medical Words

         appendectomy                                      (ap-pen-DEK-toh-mee)
            arthritis                                            (ar-THRY-tis)
             gastric                                               (GAS-trik)
           laryngitis                                           (LAIR-in-JY-tis)
         mammography                                        (mah-MAWG-rah-fee)
          pneumonia                                          (noo-MOH-nee-ah)
           therapist                                           (THAIR-ah-pist)




Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Medical Record

• The medical record is where healthcare
  professionals document all care provided
  to a patient.
• Contains not only medical documents but
  those that are also legal documents that
  can be used in a court of law.



  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Health Record

• The paper medical record has been the
  traditional form of a medical record, but it
  has some disadvantages:
   – Only one person can access it at a time.
   – It can become lost or damaged, and it can take
     time to retrieve a patient’s past medical
     records.
   – This delay can compromise the delivery of
     quality care.
  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Computerized Patient Records

• More offices, hospitals, and other
  healthcare facilities are converting to
  computerized patient records (CPRs).
• Healthcare professionals can have
  immediate access to both current and
  previous medical records.



  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Figure 1-6 Computerized patient record.(CPR).


Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
The Electronic Patient Record

• In the future, an all-encompassing
  electronic patient record (EPR), electronic
  medical record (EMR), or electronic health
  record (EHR) will provide seamless,
  immediate, and simultaneous access by
  many healthcare professionals to all parts
  of a patient’s record regardless of where
  those parts were created or stored.

  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Standard Headings in Hospital
Admission and Discharge Documents
•   Chief Complaint (CC)
•   History of Present Illness (HPI)
•   Past Medical (and Surgical) History (PMH)
•   Social History (SH) and Family History (FH)




    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Standard Headings

•   Review of Systems (ROS)
•   Physical Examination (PE)
•   Laboratory and X-ray Data
•   Diagnosis (Dx)
•   Disposition




    Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Types of Documents in the
       Medical Record
• Consent to Treatment Forms
  – Before patients can be treated at any type of
    healthcare facility, they must sign consent to
    treatment forms that give the physicians and
    other healthcare professionals the right to
    treat them.
         Treatment without consent is against the law and is
          considered to be battery (touching another person
          without his or her consent).


 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Types of Documents in the
       Medical Record
• Consent to Treatment Forms
  – For patients who are minors, the parent or
    legal guardian signs the consent to treatment.
         In an emergency situation, care is provided until
          the appropriate person is able to consent.




 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Types of Documents in the
       Medical Record
• Informed Consent
  – Patients must sign another consent form if
    they are to have surgery.
  – Prior to a surgery, the physician describes the
    purpose of the surgery and informs the patient
    of alternatives, risks, and possible
    complications.
  – If patients elect to proceed with the surgery,
    they sign the form, thus giving informed
    consent.
 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Types of Documents in the
        Medical Record
• The Health Insurance Portability and
  Accountability Act (HIPAA) of 1996.

   Patients must also sign a form that allows
     the facility to contact their insurance
     companies to obtain payment for the
     health care provided.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Types of Documents in the
        Medical Record
• The Health Insurance Portability and
  Accountability Act (HIPAA) of 1996.

   All healthcare settings must provide patients
      with a statement verifying that their
      medical record information is secure and
      is only released to authorized healthcare
      providers, insurance companies, or to
      healthcare quality monitoring
      organizations.




  Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.
Abbreviations




Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS   Copyright ©2011 All rights reserved.

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Ch01 in open campus_2013_wo_questions

  • 1. Medical Terminology for Healthcare Professionals The Structure of Medical Language Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 2. Learning Objectives 1. Identify the five skills of medical language communication. 2. Describe the origins of medical language. 3. Recognize common Latin and Greek singular nouns and form their plurals. 4. Describe characteristics of combining forms, suffixes, and prefixes. 5. Give the medical meaning of common word parts. 6. Build medical words from word parts and divide medical words into word parts. 1. Spell and pronounce common medical words. Describe the format and contents of common medical documents. 2. Dive deeper into the structure of medical language by reviewing the activities at the end of this chapter and online at Medical Terminology Interactive. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 3. Welcome to Medical Language! Medical language is the language of the healthcare profession, and medical words are the tools of the trade. Learning medical language is your key to a successful career in the healthcare field. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 4. Medical Language and Communication Communication in any language consists of five language skills. These same five language skills are important in medical language:  Reading  Listening  Thinking, analyzing, and understanding  Writing (or typing) and spelling  Speaking and pronouncing Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 5. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 6. The Beginning of Medical Language Etymology is the study of word origins and derivations. • Many words have been derived from other languages. • 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. Greek Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 7. The Beginning of Medical Language • Some medical words are identical to Latin or Greek words. • Some medical words are similar (but not identical) to Latin or Greek words. • Some medical words are similar to words from old English, Dutch, and French. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 8. The Beginning of Medical Language Medical Word Language of Origin nucleus Latin nucleus pelvis Latin pelvis sinus Latin sinus paranoia Greek paranoia thorax Greek thorax Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 9. The Beginning of Medical Language Medical Word Language of Origin artery Latin arteria muscle Latin musculus vein Latin vena phobia Greek phobos sperm Greek sperma Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 10. The Beginning of Medical Language Medical Word Language of Origin bladder English blaedre heart English heorte drug Dutch droog physician French physicien Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 11. Medical Singular and Plural Nouns Many medical terms come from Greek or Latin words Rules for 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 Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 12. Medical Singular and Plural Nouns Latin Singular How to Form the Example Ending Plural -a Change -a to -ae vertebra → vertebrae -us Change -us to -i bronchus → bronchi -um Change -um to -a bacterium → bacteria -is Change -is to -es testis → testes Change -ex to -ices apex → apices -ex, -ix Change -ix to -ices helix → helices Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 13. Medical Singular and Plural Nouns Greek Singular How to Form the Example Ending Plural -is Change -is to -ides iris → irides -nx Change -nx to -nges phalanx → phalanges -oma Change -oma to -omata fibroma → fibromata -on Change -on to -a ganglion → ganglia Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 14. Medical Words and Word Parts • Medical language contains medical words. • Most medical words contain word parts. • Word parts are puzzle pieces that, when fit together, build a medical word. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 15. Medical Words and Word Parts (con't) • There are three different kinds of word parts. – Combining forms – Suffixes – Prefixes Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 16. Medical Words and Word Parts (con’t) Word Part Meaning combining form the foundation of the word suffix the word ending prefix an optional word beginning Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 17. Figure 1-3 Combining form Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 18. Medical Word Parts • Characteristics of a Combining Form  The foundation of a word  Gives the word its main medical meaning.  Has a root, a forward slash, a combining vowel, and a final hyphen. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 19. Medical Word Parts combining vowel Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 20. Medical Word Parts (con't) • Characteristics of a Combining Form – Most medical words contain a combining form. – Sometimes a medical word contains two or more combining forms, one right after the other. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 21. Common Combining Forms Combining Form Medical Meaning abdomin/o- abdomen append/o- appendix arteri/o- artery intestin/o- intestine laryng/o- larynx (voice box) muscul/o- muscle thyroid/o- thyroid gland tonsill/o- tonsil veno- vein Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 22. Common Combining Forms Combining Form Medical Meaning arthr/o- joint cardi/o- heart derm/o- skin gastr/o- stomach mamm/o- breast nas/o- nose psych/o- mind Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 23. Common Combining Forms Combining Form Medical Meaning cholecyst/o- gallbladder cost/o- rib enter/o- intestine hepat/o- liver hyster/o- uterus lapar/o- abdomen Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 24. Medical Word Parts: Suffixes • Characteristics of a Suffix – A suffix is a word part that is at the end of a word. – A suffix modifies or clarifies the medical meaning of the combining form. – A suffix is a single letter or group of letters that begins with a hyphen. – Most medical words contain a suffix. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 25. Figure 1-4 Suffix. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 26. Suffixes for Adjective Forms Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 27. Suffixes for Adjective Forms Suffix Medical Meaning Example and Definition -ac pertaining to cardiac (pertaining to the heart) intestinal (pertaining to the -al pertaining to intestine) muscular (pertaining to the -ar pertaining to muscle) -ary pertaining to urinary (pertaining the urine) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 28. Suffixes for Adjective Forms Suffix Medical Meaning Example and Definition -ic pertaining to pelvic (pertaining to the pelvis) uterine (pertaining to the -ine pertaining to uterus) digestive (pertaining to -ive pertaining to digestion) -ous pertaining to venous (pertaining to the vein) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 29. Suffixes for Processes Suffix Medical Meaning Example and Definition a process; being or -ation urination (a process of [making] urine) having -ion action; condition digestion (action of breaking down food) process of breaking hemolysis (process of breaking down or -lysis down or destroying destroying blood) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 30. Suffixes for Diseases and Conditions Suffix Medical Meaning Example and Definition -ia condition; state; thing pneumonia (condition of the lung) process; disease from a hypothyroidism (disease from the specific -ism specific cause cause of deficient thyroid hormone) inflammation of; infection -itis tonsillitis (inflammation of the tonsil) of -megaly enlargement cardiomegaly (enlargement of the heart) -oma tumor; mass neuroma (tumor of the nerve) condition; abnormal -osis psychosis (abnormal condition of the mind) condition; process -pathy disease, suffering arthropathy (disease of the joint) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 31. Suffixes for Diagnostic, Medical, and Surgical Procedures Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 32. Suffixes for Diagnostic, Medical, and Surgical Procedures Suffix Medical Meaning Example and Definition appendectomy (surgical excision -ectomy surgical excision of the appendix) mammogram (a record or picture -gram a record or picture the breast) mammography (process of -graphy process of recording recording the breast) spirometry (process of measuring -metry process of measuring the breath) instrument used to colonoscope (instrument used to -scope examine examine the colon) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 33. Suffixes for Diagnostic, Medical, and Surgical Procedures (con't) Suffix Medical Meaning Example and Definition gastroscopy (process of using an process of using an -scopy instrument to examine the instrument to examine stomach) surgically created colostomy (surgically creating an -stomy opening opening in the colon) -therapy treatment psychiatry (treatment of the mind) process of cutting or laparotomy (process of making an -tomy making an incision incision in the abdomen) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 34. Suffixes for Medical Specialties Suffix Medical Meaning Example and Definition psychiatry (medical treatment for -iatry medical treatment the mind) therapist (one who specializes in -ist one who specializes in therapy) -logy the study of cardiology (the study of the heart) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 35. Medical Word Parts: Prefixes • Characteristics of a Prefix – A prefix is a word part that, if present, is at the beginning of a word. – A prefix modifies or clarifies the medical meaning of the combining form. – A prefix is a single letter or group of letters that ends with a hyphen. – Occasionally, a medical word has two prefixes. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 36. Figure 1-5 Prefix Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 37. Prefixes for Location or Direction Prefix Medical Meaning Example and Definition endotracheal (pertaining to endo- innermost; within within the trachea) epidermal (pertaining to upon epi- upon; above the skin) intercostal (pertaining to inter- between between the ribs) intravenous (pertaining to intra- within within a vein) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 38. Prefixes for Location or Direction Prefix Medical Meaning Example and Definition pericardial (pertaining to peri- around around the heart) postnasal (pertaining to behind post- after; behind the nose) premenstrual (pertaining to pre- before; in front of before menstruation) below; underneath; less subcutaneous (pertaining to sub- than underneath the skin) transvaginal (pertaining to trans- across; through through the vagina) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 39. Prefixes for Amount, Number, or Speed Prefix Medical Meaning Example and Definition bi- two bilateral (pertaining to two sides) bradycardia (condition of a slow brady- slow heart) hemiplegia (condition of one half hemi- one half [of the body] with paralysis) hypertension (condition of more hyper- above; more than normal than normal pressure) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 40. Prefixes for Amount, Number, or Speed Prefix Medical Meaning Example and Definition hypothyroidism (disease from a hypo- below; deficient specific cause of deficient thyroid gland [hormone]) mononucleosis (abnormal condition of [white blood cells mono- one; single that each have] one [large] nucleus) polyneuritis (inflammation of poly- many; much many nerves) quadriplegia (condition of four quadri- four [limbs] with paralysis) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 41. Prefixes for Amount, Number, or Speed Prefix Medical Meaning Example and Definition tachycardia (condition of a fast tachy- fast heart) trigeminal (pertaining to three tri- three [nerve branches in a] group) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 42. Prefixes for Degree or Quality Prefix Medical Meaning Example and Definition Aspermia a- away from; without (condition [of being] without sperm) anesthesia an- without; not (condition [of being] without sensation) antibiotic anti- against (pertaining to against living organisms) dementia de- reversal of; without (condition [of being] without a mind) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 43. Prefixes for Degree or Quality Prefix Medical Meaning Example and Definition dysphagia dys- painful; difficult; abnormal (condition of painful or difficult eating and swallowing) euthyroidism eu- normal; good (process of normal thyroid gland [function]) Malnutrition mal- bad; inadequate (being or having inadequate nourishment) respiration re- again and again (a process of again and again breathing) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 44. Analyze and Define Words: Combining Form and Suffix • Divide the medical word into its combining form and suffix. • Define each word part. • Put the word part meanings in this order: meaning of the suffix first, followed by the meaning of the combining form. • Add small connecting words, if needed, to make a correct and complete definition of the medical word. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 45. Analyze and Define Words: Combining Form, Suffix and Prefix • Divide the medical word into its prefix, combining form and suffix. • Define each word part. Let’s dissect a word …… lo gy nt ero st roe ga Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 46. Analyze and Define Words: Combining Form, Suffix and Prefix • Put the word part meanings in this order: meaning of the suffix first, followed by the meaning of the prefix, followed by the meaning of the combining form. • Add small connecting words, if needed, to make a correct and complete definition of the medical word. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 47. Building Medical Words: Suffix that Begins with a Consonant • Select the suffix and combining form whose meanings match the definition of the medical word. • Change the order of the word parts to put the suffix last. • Delete the forward slash and hyphen from the combining form. Delete the hyphen from the suffix. • Join the two word parts. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 48. Building Medical Words: Suffix that Begins with a Consonant Medical Word Word Part Word Part Meaning combining form cardiology heart cardi/o- suffix -logy the study of Medical Word Definition the study of the heart Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 49. Building Medical Words: Suffix that Begins with a Vowel • Select the suffix and combining form whose meanings match the definition of the medical word. • Change the order of the word parts to put the suffix last. • Delete the forward slash, combining vowel, and hyphen from the combining form. Delete the hyphen from the suffix. • Join the two word parts. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 50. Building Medical Words: Suffix that Begins with a Vowel Medical Word Word Part Word Part Meaning combining form cardiac heart cardi/o- suffix -ac pertaining to Medical Word Definition pertaining to the heart Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 51. Building Medical Words: Contains a Prefix • Select the suffix, prefix and combining form whose meanings match the definition of the medical word. • Change the order of the word parts to put the suffix last. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 52. Building Medical Words: Contains a Prefix • Delete the hyphen from the prefix. Delete the forward slash, combining vowel, and hyphen from the combining form. Delete the hyphen from the suffix. • Join the three word parts. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 53. Building Medical Words: Contains a Prefix Medical Word Word Part Word Part Meaning combining form intracardiac heart cardi/o- suffix -ac pertaining to prefix intra- within Medical Word Definition pertaining to within the heart Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 54. Pronounce Medical Words • Knowing the definition of a medical word is important. • Being able to pronounce the medical word correctly is equally important. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 55. Pronounce Medical Words • Follow these simple directions for pronouncing medical words: – Say each syllable by following the “see-and- say” pronunciation guide. – Accented syllables are in all capital letters. – Secondary accented syllables are in smaller capital letters. – Practice pronouncing the word several times until you have mastered its pronunciation. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 56. Pronounce Medical Words appendectomy (ap-pen-DEK-toh-mee) arthritis (ar-THRY-tis) gastric (GAS-trik) laryngitis (LAIR-in-JY-tis) mammography (mah-MAWG-rah-fee) pneumonia (noo-MOH-nee-ah) therapist (THAIR-ah-pist) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 57. The Medical Record • The medical record is where healthcare professionals document all care provided to a patient. • Contains not only medical documents but those that are also legal documents that can be used in a court of law. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 58. The Health Record • The paper medical record has been the traditional form of a medical record, but it has some disadvantages: – Only one person can access it at a time. – It can become lost or damaged, and it can take time to retrieve a patient’s past medical records. – This delay can compromise the delivery of quality care. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 59. Computerized Patient Records • More offices, hospitals, and other healthcare facilities are converting to computerized patient records (CPRs). • Healthcare professionals can have immediate access to both current and previous medical records. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 60. Figure 1-6 Computerized patient record.(CPR). Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 61. The Electronic Patient Record • In the future, an all-encompassing electronic patient record (EPR), electronic medical record (EMR), or electronic health record (EHR) will provide seamless, immediate, and simultaneous access by many healthcare professionals to all parts of a patient’s record regardless of where those parts were created or stored. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 62. Standard Headings in Hospital Admission and Discharge Documents • Chief Complaint (CC) • History of Present Illness (HPI) • Past Medical (and Surgical) History (PMH) • Social History (SH) and Family History (FH) Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 63. Standard Headings • Review of Systems (ROS) • Physical Examination (PE) • Laboratory and X-ray Data • Diagnosis (Dx) • Disposition Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 64. Types of Documents in the Medical Record • Consent to Treatment Forms – Before patients can be treated at any type of healthcare facility, they must sign consent to treatment forms that give the physicians and other healthcare professionals the right to treat them.  Treatment without consent is against the law and is considered to be battery (touching another person without his or her consent). Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 65. Types of Documents in the Medical Record • Consent to Treatment Forms – For patients who are minors, the parent or legal guardian signs the consent to treatment.  In an emergency situation, care is provided until the appropriate person is able to consent. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 66. Types of Documents in the Medical Record • Informed Consent – Patients must sign another consent form if they are to have surgery. – Prior to a surgery, the physician describes the purpose of the surgery and informs the patient of alternatives, risks, and possible complications. – If patients elect to proceed with the surgery, they sign the form, thus giving informed consent. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 67. Types of Documents in the Medical Record • The Health Insurance Portability and Accountability Act (HIPAA) of 1996. Patients must also sign a form that allows the facility to contact their insurance companies to obtain payment for the health care provided. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 68. Types of Documents in the Medical Record • The Health Insurance Portability and Accountability Act (HIPAA) of 1996. All healthcare settings must provide patients with a statement verifying that their medical record information is secure and is only released to authorized healthcare providers, insurance companies, or to healthcare quality monitoring organizations. Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.
  • 69. Abbreviations Florida State College of Jacksonville | Professor: Michael L. Whitchurch, MHS Copyright ©2011 All rights reserved.

Hinweis der Redaktion

  1. Welcome to the first unit of learning medical language. We begin with a study of how medical terms are structured… this will be the basis of how you will learn this language. The approach is not the traditional ‘vocabulary words’ you experienced in grade school… you will not be learning a word and memorizing its definition. The method presented is referred to “word building” … you will be learning parts of words or medical terms and using those words in healthcare settings. As we move through each medical specialty and body system you will be reusing word parts learned in previous units. So, that said, it is absolutely imperative that you no skip or fall behind in learning new word parts that will be introduced with each unit of study. Just as in math, if you skipped how to subtract or add you would not be successful in mastering division. One more thing before we get into this foundational unit … you will be learning beginning anatomy and physiology, not only because this study contains medical terminology, it is the ‘context’ for all the terms … if you learn a medical term related to a disease or procedure and don’t know the what and where of those terms you will not really know the language you speak. Now on to the structure of medical language … first our road map for this unit… the learning objectives, the walk away you should carry forward to subsequent units.