Whole terms Flashcards
word root
the fundamental meaning for the word
prefix
a word part that is affixed before the root that modifies the meaning
suffix
a word part that is affixed after the root that modifies the meaning
combining vowel
a vowel whose purpose is to connect two word parts
–> Usually “o”
medical record
chart documents that details a patient’s hospital stay
Electronic Medical Record (EMR)
a digital medical record
History and Physical
written or dictated by admitting physician; details patient’s history, results of physician’s examination, initial diagnoses, and physicians’ plan of treatment
Physician’s Orders
complete list of care, medications, tests, and treatments physician orders for patient
Nurses’s Notes
record of patient’s care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment, and patient’s condition
Physician’s Progress Notes
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
Consultation Reports
reports given by specialists whom physician has asked to evaluate patient
Ancillary Reports
reports from various treatments and therapies patient has received, such as rehabilitation, social services, or respiratory therapy
Diagnostic Reports
results of diagnostic tests performed on patient, principally from clinical lab (e.g., blood tests) and medical imaging (e.g., X-rays and ultrasound)
Informed Consent
document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure
Operative Report
report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure
Anesthesiologist’s Report
relates details regarding substances (such as medications and fluids) given to patient, patient’s response to anesthesia, and vital signs during surgery
Pathologist’s Report
report given by pathologist who studies tissue removed from patient (e.g., bone marrow, blood, or tissue biopsy)
Discharge Summary
comprehensive outline 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 plants
Acute Care or General Hospitals
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 obstetrician care
Specialty Care Hospitals
Provide care for very specific types of diseases; for example, a psychiatric hospital
Nursing Homes or Long-Term Care Facilities
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
Ambulatory Care Centers, Surgical Centers, or Outpatient Clinics
Provide services not requiring overnight hospitalization; services range from simple surgeries to diagnostic testing or therapy
Physicians’ Offices
Provide diagnostic and treatment services in a private office setting
Health Maintenance Organization (HMO)
Provides wide range of services by a group of primary-care physicians, specialists, and other healthcare professionals in a prepaid system
