MT Ch. 1 Flashcards

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0
Q

Medical record

A

Paper chart that documents details of patients hospital stay

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1
Q

4 Elements of Medical Terms

A
  1. Word root- often indicate part or action
  2. Prefix- location of organ, # of parts, or time
  3. Suffix- condition, disease, or procedure
  4. Combining vowel- usually “O”, used between root and suffix if suffix begins with a consonant
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2
Q

Electronic medical record (EMR)

A

Digitally stored record that documents details of patients hospital stay

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3
Q

History and Physical

A

-patient history, exam results, initial diagnosis, and treatment plan written by admitting physician

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4
Q

Physicians orders

A

Complete list of care, meds, tests, and treatments physician orders for patient

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5
Q

Nurses notes

A

Treatment throughout the day and vital signs, specifics, patient response, and condition

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6
Q

Physician progress notes

A

Contains updated assessment, diagnoses, and further plans of care

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7
Q

Consultation reports

A

Report given by a specialist

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8
Q

Ancillary reports

A

Reports from various treatments received

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9
Q

Diagnostic reports

A

Results of diagnostic tests, usually clinical lab and medical imaging

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10
Q

Informed consent

A

Document signed by patient/responsible party that describes purpose, methods, benefits, and risks of procedure

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11
Q

Operative report

A

Diagnosis and and operation details written by the surgeon

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12
Q

Anesthesiologists report

A

Details of substances given, patient response, and vital signs during surgery

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13
Q

Pathologists report

A

Details regarding tissue removes from patient

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14
Q

Discharge summary

A

Documents entire hospital stay, from admitting diagnosis to final diagnosis and follow up

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15
Q

Acute Care/ General Hospitals

A

Diagnose and treat diseases for short time periods, offer ER

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16
Q

Specialty Care Hospitals

A

Provide care for specific diseases

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17
Q

Nursing Homes/Long Term Care Facilities

A

People who can’t take care of themselves and people who need extra recovery time

18
Q

Ambulatory Care Centers, Surgical Centers, Outpatient Clinics

A

Services not requiring overnight stay; from simple surgeries to testing and therapy

19
Q

Physicians offices

A

Diagnostic and treatment services in a private setting

20
Q

Health Maintenance Organization (HMO)

A

Prepaid system of services by primary-care physicians, specialists, and other providers

21
Q

Home health care

A

Provides personal care in patients home

22
Q

Rehab centers

A

Intensive PT and OT; inpatient and outpatient treatment

23
Q

Hospices

A

Supportive treatment to terminally ill patients and their families

24
Q

Organization of Body

A

Cells, tissues, organs, systems, body

25
Q

Cytology

A

Study of cells and their function

26
Q

Cell membrane

A

Outermost boundary of a cell

27
Q

Cytoplasm

A

Watery internal environment of cell

28
Q

Nucleus

A

Contains cells DNA

29
Q

What does a cell always have no matter it’s shape?

A

Nucleus, cytoplasm, cell membrane

30
Q

Histology

A

Study of tissues

31
Q

Tissues

A

When cells grouped together function to perform a specific activity

32
Q

4 Types of Body Tissues

A

Epithelial, connective, muscle, nervous

33
Q

Muscle tissue

A
  • produce movement through contraction
  • composed of muscle fibers
  • forms skeletal muscle, smooth muscle, cardiac muscle
34
Q

Skeletal muscle

A

Attached to bone

35
Q

Smooth muscle

A

Found in internal organs such as intestine and blood vessels

36
Q

Cardiac muscle

A

Found only in the heart

37
Q

Epithelial tissue

A
  • Covers and lines body structures

- can absorb substances, secrete substances, or excrete wastes

38
Q

Connective tissue

A
  • supporting and protecting tissue

- bone, cartilage, tendons, and adipose

39
Q

Bone

A

Provides structural support for the whole body

40
Q

Cartilage

A

Shock absorber in joints

41
Q

Tendons

A

Connect skeletal muscles to bones

42
Q

Adipose

A

Provides protective padding around body structures

43
Q

Nervous tissue

A
  • composed of neurons

- forms brain, spinal cord, and network of nerves