Introduction to Medical Terminology

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1
Introduction to Medical Terminology
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Multimedia Directory

• Slide 52 Medical Transcriptionist Video
• Slide 54 Patient Histories Video 1
• Slide 55 Patient Histories Video 2
• Slide 73 HIPAA Video

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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

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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

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Figure 1.1Nurse completing a patient report.
Healthcare workers use medical terminology in
order to accurately and efficiently communicate
patient information to each other.
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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

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Medical Terms Are Built from Word Parts

• Word Part
• Word root
• Prefix
• Suffix
• Combining form

• Example (Meaning)
• cardiogram (record of the heart)
• pericardium (around the heart)
• carditis (inflammation of the heart)
• cardiomyopathy (heart muscle disease)

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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

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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

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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

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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

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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

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Combining Form

• Typically used to write word roots
• Also use the word root/combining vowel format
• Examples
• cardi/o
• arthr/o
• gastr/o

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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

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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

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Common Combining Forms

• ot/o ear
• path/o disease
• pulmon/o lung
• rhin/o nose

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Prefix

• Added to the front of a term
• Adds meaning such as
• location of organ sub- below
• number of parts mono- one
• time (frequency) post- after

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Prefix

• Not all medical terms have a prefix
• When written by itself, followed by a hyphen
• intra-
• hyper-
• multi-

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Common Prefixes

• a- without, away from
• an- without
• ante- before, in front of
• anti- against
• auto- self
• brady- slow
• contra- against
• de- without

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Common Prefixes

• dys- painful, difficult, abnormal
• endo- within, inner
• epi- upon, over
• eso- inward
• eu- normal, good
• ex- external, outward
• exo- outward
• extra- outside of

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Common Prefixes

• hetero- different
• homo- same
• hydro- water
• hyper- over, above
• hypo- under, below
• in- not, inward
• inter- among, between
• intra- within, inside

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Common Prefixes

• macro-
• micro-
• myo-
• neo-
• pan-
• para-
• per-
• peri-

• large
• small
• to shut
• new
• all
• beside, near, abnormal, two like parts of a pair
• through
• around

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Common Prefixes

• post- after
• pre- before, in front of
• pro- before
• pseudo- false
• retro- backward, behind
• sub- below, under
• supra- above
• tachy- fast

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Common Prefixes

• trans- through, across
• ultra- beyond, excess
• un- not

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Number Prefixes

• bi- two
• hemi- half
• mono- one
• multi- many
• nulli- none
• poly- many

• primi- first
• quadri- four
• semi- partial, half
• tetra- four
• tri- three

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Suffix

• Attached to the end of a term
• Adds meaning such as
• condition -algia pain
• disease -itis inflammation
• procedure -ectomy surgical removal

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Suffix

• All medical terms must have a suffix
• Only mandatory word part
• When written by itself, precede with a hyphen
• -logy
• -sclerosis
• -cyte

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Common Suffixes

• -algia pain
• -cele hernia, protrusion
• -cyte cell
• -dynia pain
• -ectasis dilatation
• -gen that which produces
• -genesis produces, generates
• -genic producing, produced by

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Common Suffixes

• -ia state, condition
• -iasis abnormal condition
• -iatry medical treatment
• -ism state of
• -itis inflammation
• -logist one who studies
• -logy study of
• -lysis destruction

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Common Suffixes

• -lytic destruction
• -malacia abnormal softening
• -megaly enlargement, large
• -oid resembling
• -oma tumor, mass
• -osis abnormal condition
• -pathy disease
• -phobia fear

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Common Suffixes

• -plasia development, growth
• -plasm formation, development
• -ptosis drooping
• -rrhage excessive, abnormal flow
• -rrhagia abnormal flow condition
• -rrhea discharge, flow
• -rrhexis rupture
• -sclerosis hardening

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Common Suffixes

• -stenosis narrowing
• -therapy treatment
• -trophy nourishment, development
• -ule small

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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

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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

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Adjective Suffixes

• -ac
• -al
• -an
• -ar
• -ary
• -atic

• -nic
• -ory
• -ose
• -ous
• -tic

• -eal
• -iac
• -ic
• -ile
• -ine
• -ior

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Surgical Suffixes

• -centesis puncture to withdraw fluid
• -ectomy surgical removal
• -ostomy surgically create an opening
• -otomy cutting into
• -pexy surgical fixation
• -plasty surgical repair
• -rrhaphy suture

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Procedural Suffixes

• -gram record or picture
• -graph instrument for recording
• -graphy process of recording
• -meter instrument for measuring
• -metry process of measuring
• -scope instrument for viewing
• -scopy process of visually examining

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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

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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

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Interpreting Medical Terms

• Term to be translated
• gastroenterology
• Divide the term into its word parts
• gastr / o / enter / o / logy

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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

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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)

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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)

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Same Sounds Spelled Differently

• Sounds like si
• psy psychiatry
• cy cytology
• Sounds like dis
• dys dyspepsia
• dis dislocation

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Singular and Plural Endings

• 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

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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

• Plural
• vertebrae
• thoraces
• appendices
• metastases
• sarcomata
• phalanges
• ganglia
• ova
• nuclei
• biopsies

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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

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Figure 1.2Health information professionals
maintain accurate, orderly, and permanent patient
records. Medical records are securely stored and
available for future reference.
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The Medical Record

• Documents details of hospital stay
• Patients 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

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The Electronic Medical Record (EMR)

• A software program
• Allows entry of patient information into a
  computer

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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

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Medical Transcriptionist Video

• Click on the screenshot to view a video on the
  duties of the medical transcriptionist.

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Common Elements of the Medical Record

• History and Physical
• Written by admitting physician
• Details patients
• History
• Exam results
• Initial diagnosis
• Physicians plan of treatment

• Physicians Orders
• Ordered by the doctor
• Complete list of
• Care
• Medications
• Tests
• Treatments

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Patient Histories Video 1

• Click on the screenshot to view a video on the
  correct manner while taking patient histories.

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Patient Histories Video 2

• Click on the screenshot to view a video on the
  wrong manner while taking patient histories.

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Common Elements of the Medical Record Notes

• Nurses Notes
• Records the patients care throughout the day
• Includes vital signs, treatment specifics,
  patients response to treatment, and patients
  condition

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Common Elements of the Medical Record Notes

• Physicians Progress Notes
• Daily record of patients condition
• Results of physical exam, summary of test
  results, updated assessment and diagnoses,
  further plans for treatment

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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

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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

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Common Elements of the Medical Record Reports

• Anesthesiologists Report
• Relates details of drugs given to patient
• Response to anesthesia
• Vital signs during surgery

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Common Elements ofthe Medical Record Reports

• Diagnostic Reports
• Results of all diagnostic tests performed on the
  patient
• From lab to medical imaging
• Pathologists Report
• Report given by pathologist who studies tissue
  removed from patient

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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

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Common Elements of the Medical Record

• Discharge Summary
• Outline of patients entire hospital stay
• Includes condition at admission, admitting
  diagnosis, test results, treatments, and
  patients response, final diagnosis, and
  follow-up plans

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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

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Figure 1.3A nurse and medical assistant review a
patients chart and plan his or her daily care.
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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

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Healthcare Settings

• Ambulatory Care, Surgical Center, or Outpatient
  Clinic
• For patients who do not need overnight care
• Simple surgeries, therapy, or diagnostic testing

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Healthcare Settings

• Physicians 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 pre-paid
  system

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Healthcare Settings

• Home Health Care
• Agencies that provide nursing, therapy, personal
  care, or housekeeping services in patients home
• Rehabilitation
• Provides physical and occupational therapy
• Inpatient and outpatient

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Healthcare Settings

• Hospice
• Organized group of health workers that provide
  supportive treatment to terminally ill patients
  and their families

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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

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Confidentiality

• Health Insurance Portability and Accountability
  Act of 1996 (HIPAA) sets federal standards to
  protect records

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HIPAA Video

• Click on the screenshot to view a video
  describing HIPAA.

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Classroom Response System
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Pop Question 1

• Which of the following is NOT one of the four
  basic word parts used to build medical terms?
• Prefix
• Combining root
• Suffix
• Word root

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Answer 1

• Which of the following is NOT one of the four
  basic word parts used to build medical terms?
• Prefix
• Combining root
• Suffix
• Word root

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Pop Question 2

• Which of the following combinations is used to
  make a combining form?
• Prefix suffix
• Prefix word root
• Word root suffix
• Word root combining vowel

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Answer 2

• Which of the following combinations is used to
  make a combining form?
• Prefix suffix
• Prefix word root
• Word root suffix
• Word root combining vowel

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Pop Question 3

• A combining vowel is NOT used
• Between two word roots
• When the suffix begins with a vowel
• When the suffix begins with a consonant
• Between a prefix and word root

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Answer 3

• A combining vowel is NOT used
• Between two word roots
• When the suffix begins with a vowel
• When the suffix begins with a consonant
• Between a prefix and word root

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Pop Question 4

• The combining form for skin is
• Dermat/o
• Gastr/o
• Cardi/o
• Nephr/o

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Answer 4

• The combining form for skin is
• Dermat/o
• Gastr/o
• Cardi/o
• Nephr/o

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Pop Question 5

• The combining form hemat/o means
• Stomach
• Small intestines
• Blood
• Nose

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Answer 5

• The combining form hemat/o means
• Stomach
• Small intestines
• Blood
• Nose

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Pop Question 6

• Which medical terminology word part gives
  information about location or time?
• Word root
• Prefix
• Combining form
• Suffix

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Answer 6

• Which medical terminology word part gives
  information about location or time?
• Word root
• Prefix
• Combining form
• Suffix

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Pop Question 7

• Which prefix means painful, difficult, or
  abnormal?
• Eu-
• Anti-
• Dys-
• Retro-

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Answer 7

• Which prefix means painful, difficult, or
  abnormal?
• Eu-
• Anti-
• Dys-
• Retro-

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Pop Question 8

• Which prefix means the opposite of brady-?
• Tachy-
• Pre-
• Trans-
• Neo-

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Answer 8

• Which prefix means the opposite of brady-?
• Tachy-
• Pre-
• Trans-
• Neo-

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Pop Question 9

• Which prefix means within or inside?
• Inter-
• Infra-
• Intra-
• Infer-

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Answer 9

• Which prefix means within or inside?
• Inter-
• Infra-
• Intra-
• Infer-

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Pop Question 10

• Which of the following is NOT information given
  by suffixes?
• Condition
• Disease
• Number
• Procedure

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Answer 10

• Which of the following is NOT information given
  by suffixes?
• Condition
• Disease
• Number
• Procedure

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Pop Question 11

• Which suffix has the same meaning as -algia?
• -dynia
• -cise
• -ectasis
• -malacia

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Answer 11

• Which suffix has the same meaning as -algia?
• -dynia
• -cise
• -ectasis
• -malacia

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Pop Question 12

• What is the meaning of the suffix -stenosis?
• Enlarged
• Hardening
• Narrowing
• Destruction

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Answer 12

• What is the meaning of the suffix -stenosis?
• Enlarged
• Hardening
• Narrowing
• Destruction

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Pop Question 13

• Which surgical suffix means to remove?
• -ectomy
• -ostomy
• -plasty
• -otomy

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Answer 13

• Which surgical suffix means to remove?
• -ectomy
• -ostomy
• -plasty
• -otomy

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Pop Question 14

• Which of the procedural suffixes means an
  instrument for recording?
• -gram
• -scope
• -graph
• -metry

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Answer 14

• Which of the procedural suffixes means an
  instrument for recording?
• -gram
• -scope
• -graph
• -metry

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Pop Question 15

• The correct plural for the medical term thorax
  is
• Thoraxae
• Thoraxes
• Thoraces
• Thoraxia

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Answer 15

• The correct plural for the medical term thorax
  is
• Thoraxae
• Thoraxes
• Thoraces
• Thoraxia

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Pop Question 16

• The use of abbreviations in medical charts is
  usually discouraged.
• True
• False

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Answer 16

• The use of abbreviations in medical charts is
  usually discouraged.
• True
• False

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Pop Question 17

• Which part of a medical record is the physicians
  daily record of the patients condition?
• History and Physical
• Consultation Report
• Physicians Orders
• Physicians Progress Note

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Answer 17

• Which part of a medical record is the physicians
  daily record of the patients condition?
• History and Physical
• Consultation Report
• Physicians Orders
• Physicians Progress Note

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Pop Question 18

• What information is found in a Diagnostic Report?
• Test results
• Details from an operation
• Rehabilitation progress
• Information from a pathologist

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Answer 18

• What information is found in a Diagnostic Report?
• Test results
• Details from an operation
• Rehabilitation progress
• Information from a pathologist

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Pop Question 19

• Another name for an acute care hospital is a(n)
• Surgical center
• General hospital
• Health maintenance organization
• Outpatient clinic

112
Answer 19

• Another name for an acute care hospital is a(n)
• Surgical center
• General hospital
• Health maintenance organization
• Outpatient clinic

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Pop Question 20

• Which healthcare setting specifically provides
  supportive treatment to terminal patients?
• Home healthcare
• Hospice
• Rehabilitation center
• Nursing home

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Answer 20

• Which healthcare setting specifically provides
  supportive treatment to terminal patients?
• Home healthcare
• Hospice
• Rehabilitation center
• Nursing home