Chapter 1 [Introduction to Medical Terminology] Terms Flashcards
the foundation of the word
word root
is at the beginning of the word
prefix
at the end of the word
suffix
is a vowel that links the word root to another word root or suffix
combining vowel
four components of medical terminology
word root, prefix, suffix, and combining vowel
what documents the details of a patient’s hospital stay?
medical record or chart
a software program that allows for entering patient info via computer or tablet, which then organizes and stores the data
Electronic Medical Record [EMR]
Written or dictated by admitting physician; deals patient’s history, results of physician’s examination, initial diagnoses, and physician’s plan of treatment
history and physical
Complete list of care, medications, tests, and treatments physician orders for patient
physician’s orders
Record of patient’s care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment and patient’s condition
nurse’s orders
Physician’s daily record of patient’s condition., results of physician’s examinations, summary of test results, updated
assessment and diagnoses, and further plans for patient’s care
physician’s progress notes
Reports given by specialists whom physician has asked to evaluate patient
consultant reports
reports from various treatments and therapies patient has received, such as rehab, social services, or RT
Ancillary Reports
Results or diagnostic tests performed on patient, principally from clinical lab (e.9., blood tests) and medical imaging
diagnostic reports
Document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures
benefits, and risks of a diagnostic or treatment procedure
informed consent
Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical
procedure itself, and how patient tolerated procedure
operative reports
Relates details regarding substances (such as medications and fluids) given to patient, patient’s response to
anesthesia, and vital signs during surgery
Anesthesiologist’s Report
Report given by pathologist who studies tissue removed from patient
pathologist’s report
Comprehensive outine of patient’s entire hospital stay, includes condition at time of admission, admitting diagnosis.
test results, treatments and patient’s response, final diagnosis, and follow-up plans
discharge summary
