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
Provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications,
therapy) diseases for a short period of time; in addition, they usually provide emergency and
obstetrical care
acute care or general hospitals
Provide care for very specific types of diseases
specialty care hospitals
Provide long-term care for patients needing extra time to recover from illness or injury before
returning home or for persons who can no longer care for themselves
Nursing Homes or Long-Term Care Facilities
Provide services not requiring overnight hospitalization; services range from simple surgeries to
diagnostic testing or therapy
Ambulatory Care Centers, Surgical Centers,
or Outpatient Clinics
Provide diagnostic and treatment services in a private office setting
Physicians’ Offices
Provides wide range of services by a group of primary-care physicians, specialists, and other
healthcare professionals in a prepaid system
Health Maintenance Organization (HMO)
Provides nursing, therapy, personal care, or housekeeping services in patient’s own home
Home Health Care
Provide intensive physical and occupational therapy; includes inpatient and outpatient treatment
Rehabilitation Centers
Provide supportive treatment to terminally ill patients and their families
hospices
set federal standards providing
patients with more protection of their medical records and health information, better access to their own records, and greater control over how their health information is used and to whom it is disclosed
HIPPA
Is the study of the origin, characteristic, and effects of drugs,
Pharmacology
describes the chemical formula of
molecular structure of a particular drug.
chemical name
is recognized and accepted as the official name for a drug.
generic or nonproprietary name
it. However, the pharmaceutical company that originally developed the drug has exclusive rights to produce it for how many years?
20 years
When a company manufactures a drug for sale, it must choose a what for its product.
brand name, or proprietary name,
what a company that manufactures a drug for sale name it is called a
trademark
a physician can indicate on a prescription if the what can substitute a generic brand for a brand name
pharmacist
can only be ordered by licensed healthcare practitioners
such as physicians, dentists, or physician assistants.
prescription drug
is the written explanation to the pharmacist regarding the name of the medication, the dosage.
and the times of administration.
prescription
A drug that does not require a prescription is referred to as an what?
over-the counter (OTC) drug
if drugs have the potential for being addictive or abused they are labeled as what?
controlled substances
enforces the control of these drugs.
The Drug Enforcement Administration (DEA)
Some of the more commonly
prescribed controlled substances are:
butabarbital
oxycontin
choral hydrate
codeine
morphine
phenobarbital
diazepam
secobarbital
Drugs with the highest potential for addiction and abuse; they are not accepted for medical use; examples are heroin and LSD
Schedule I
Drugs with a high potential for addiction and abuse accepted for medical use in the United States; examples are codeine, cocaine, morphine, opium, and secobarbital
Schedule II
Drugs with a moderate to low potential for addiction and abuse; examples are butabarbital, anabolic steroids, and acetaminophen with codeine
Schedule III
Drugs with a lower potential for addiction and abuse than Schedule Ill drugs; examples are chloral hydrate, phenobarbital, and diazepam
Schedule IV
Drugs with a low potential for addiction and abuse; an example is low-strength codeine combined with other drugs to suppress coughing
Schedule V
to be taken by mouth,
po
three times a day
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