MT Ch. 1 Flashcards
Medical record
Paper chart that documents details of patients hospital stay
4 Elements of Medical Terms
- Word root- often indicate part or action
- Prefix- location of organ, # of parts, or time
- Suffix- condition, disease, or procedure
- Combining vowel- usually “O”, used between root and suffix if suffix begins with a consonant
Electronic medical record (EMR)
Digitally stored record that documents details of patients hospital stay
History and Physical
-patient history, exam results, initial diagnosis, and treatment plan written by admitting physician
Physicians orders
Complete list of care, meds, tests, and treatments physician orders for patient
Nurses notes
Treatment throughout the day and vital signs, specifics, patient response, and condition
Physician progress notes
Contains updated assessment, diagnoses, and further plans of care
Consultation reports
Report given by a specialist
Ancillary reports
Reports from various treatments received
Diagnostic reports
Results of diagnostic tests, usually clinical lab and medical imaging
Informed consent
Document signed by patient/responsible party that describes purpose, methods, benefits, and risks of procedure
Operative report
Diagnosis and and operation details written by the surgeon
Anesthesiologists report
Details of substances given, patient response, and vital signs during surgery
Pathologists report
Details regarding tissue removes from patient
Discharge summary
Documents entire hospital stay, from admitting diagnosis to final diagnosis and follow up
Acute Care/ General Hospitals
Diagnose and treat diseases for short time periods, offer ER
Specialty Care Hospitals
Provide care for specific diseases