1. 1
Introduction to Medical Terminology

2. Learning Outcomes
Describe the fundamental elements that are used to build medical words.
List three guidelines for building and spelling medical words.
Explain the use of abbreviations when writing and documenting data.

3. Learning Outcomes Analyze, build, spell, and pronounce medical words.
Identify and define selected abbreviations.
Describe selected medical and surgical specialties, giving the scope of practice and the physician’s title.

4. Learning Outcomes Define HIPAA.
List and describe the general components of a patient’s medical record.
List and describe the four parts of the SOAP Chart Note record. 4

5. Comprehension of Fundamental Word Structure
Medical terminology is the study of terms that are used in the art and science of medicine.
Because of advances in scientific computerized technology, many new terms are coined daily; however, most of these terms are composed of word parts that have their origins in ancient Greek or Latin. 5

6. Fundamentals of Word Structure
The fundamental elements in medical terminology are the component parts used to build medical words.
The abbreviations used for component parts in this text are P for prefix, R for root, CF for combining form, and S for suffix. 6

7. Prefix
Prefix means to fix before or to fix to the beginning of a word.
A prefix can be a syllable or a group of syllables placed at the beginning of a word to alter or modify the meaning of the word or to create a new word.

8. Word Root
A root is a word or word element from which other words are formed.
It is the foundation of the word and conveys the central meaning of the word.
It forms the base to which prefixes and suffixes are attached for word modification.

9. Combining Form
A combining form is a word root to which a vowel has been added to link the root to the suffix or to another root.
The vowel o is used more often than any other to make combining forms.

10. Suffix Suffix means to fasten on, beneath, or under.
A suffix can be a syllable or group of syllables united with or placed at the end of a word to alter or modify the meaning of the word or to create a new word.

11. Principles of Component Parts
As you learn definitions for prefixes, roots, combining forms, and suffixes, you will discover that some component parts have the same meanings as others, which can be traced to differences in the Greek or Latin words from which they originated.

12. Principles of Component Parts
Most of the terms for the body's organs originated from Latin words, whereas terms describing diseases that affect these organs have their origins in Greek.

13. Identification of Medical Words
You will learn to distinguish among and select the appropriate component parts for the meaning of the word.

14. Spelling
Medical words of Greek origin are often difficult to spell because many begin with a silent letter or have a silent letter within the word.
Correct spelling is extremely important in medical terminology because the addition or omission of a single letter can change the meaning of the word.

15. Spelling 15

16. Spelling 16

17. Spelling 17

18. Spelling 18

19. Spelling 19

20. Spelling
Follow these guidelines for building and spelling medical words:
If the suffix begins with a vowel, drop the combining vowel from the combining form and add the suffix.
If the suffix begins with a consonant, keep the combining vowel and add the suffix to the combining form.
Keep the combining vowel between two or more roots in a term.

21. Formation of Plural Endings
To change the following singular endings to plural endings, substitute the plural endings as illustrated:
a as in bursa
to ae as in bursae
ax as in thorax
to aces as in thoraces or es as
in thoraxes
en as in foramen
to ina as in foramina
is as in crisis
to es as in crises

22. Formation of Plural Endings
To change the following singular endings to plural endings, substitute the plural endings as illustrated:
is as in iris
to ides as in irides
is as in femoris
to a as in femora
ix as in appendix
to ices as in appendices
nx as in phalanx
to ges as in phalanges

23. Formation of Plural Endings
To change the following singular endings to plural endings, substitute the plural endings as illustrated:
on as in spermatozoon
to a as in spermatozoa
um as in ovum
to a as in ova
us as in nucleus
to i as in nuclei
y as in artery
to i and add es as in arteries

24. Use of Abbreviations
An abbreviation is a process of shortening a word or phrase into appropriate letters.
It is used as a form of communication in writing and documenting data.
If there is any question about which abbreviation to use, it is best to spell out the word or phrase and not use an abbreviation.

25. Pronunciation
A single accent mark (') is called a primary accent and is used with the syllable that has the strongest stress.
A double accent mark (") is called a secondary accent and is given to syllables that are stressed less than primary syllables.

26. Pronunciation
Diacritics are marks placed over or under vowels to indicate the long or short sound of the vowel.
Macron ( ¯ ) – the long sound of the vowel.
Breve ( ˘ ) – the short sound of the vowel.
Schwa ( ə ) – indicates the uncolored, central vowel sound of most unstressed syllables.

27. Audio Pronunciations
Abate
Abnormal
Abscess
Acute
Adhesion

28. Audio Pronunciations
Afferent
Ambulatory
Antidote
Antipyretic 28

29. Audio Pronunciations
Antiseptic
Antitussive
Apathy
Asepsis

30. Audio Pronunciations
Autoclave
Autonomy
Axillary
Biopsy
Cachexia 30

31. Audio Pronunciations Centigrade Centimeter Centrifuge Chemotherapy
Chronic

32. Audio Pronunciations
Diagnosis
Diaphoresis
Disease
Disinfectant 32

33. Audio Pronunciations
Efferent
Empathy
Epidemic
Etiology

34. Audio Pronunciations
Excision
Febrile
Gram
Heterogeneous
Illness 34

35. Audio Pronunciations
Incision
Kilogram
Liter
Macroscopic
Malaise

36. Audio Pronunciations
Malformation
Malignant
Maximal
Microgram 36

37. Audio Pronunciations
Microorganism
Microscope
Milligram
Milliliter

38. Audio Pronunciations
Minimal
Multiform
Necrosis
Neopathy
Oncology 38

39. Audio Pronunciations
Pallor
Palmar
Paracentesis
Prognosis

40. Audio Pronunciations Prophylactic Pyrogenic Radiology Rapport Syndrome40

41. Audio Pronunciations
Thermometer
Topography
Triage

42. Insert Table 1-1

43. Insert Table 1-1 43

44. Selected Medical and Surgical Specialties
Table 1.1 (continued)
Selected Medical and Surgical Specialties 44

45. Selected Medical and Surgical Specialties
Table 1.1 (continued)
Selected Medical and Surgical Specialties 45

46. Insert Table 1-1 46

47. Selected Medical and Surgical Specialties
Table 1.1 (continued)
Selected Medical and Surgical Specialties 47

48. Selected Medical and Surgical Specialties
Table 1.1 (continued)
Selected Medical and Surgical Specialties 48

49. Insert Table 1-1 49

50. Insert Table 1-2 50

51. The Medical Record
The medical record is a written document of information describing a patient and his or her health care.
The record contains the dates, observations, medical or surgical interventions, and treatment outcomes provided during hospitalization or a visit to a doctor’s office. 51

52. The Medical Record
It includes information that the patient provides concerning his or her symptoms (Sx) and medical history, results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans.
The physical medical record belongs to the health care provider, but the information in it belongs to the patient. 52

53. The Medical Record Basis for planning care and treatment.
Means by which doctors, nurses, and others caring for the patient can communicate.
Legal document describing the care the patient received and can be used as evidence in court.
Manuscript, p. 33, has two additional paragraphs in the Medical Record section. Should this information be included in the PPT presentation? 53

54. The Medical Record
Means by which the patient or insurance company can verify that services billed were actually provided.
Manuscript, p. 33, has two additional paragraphs in the Medical Record section. Should this information be included in the PPT presentation? 54

55. The Medical Record
Health Insurance Portability and Accountability Act (HIPAA)
Set of rules passed in 1996 that must be followed by doctors, hospitals, and other health care providers to help ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy. 55

56. The Medical Record
Health Insurance Portability and Accountability Act (HIPAA)
Requires that all patients be able to access their own medical records, correct errors or omissions, and be informed about how personal information is shared or used and about privacy procedures. 56

57. The Medical Record Types of Medical Records Paper
Microfilm – photographs of records in a reduced size
Microfiche – sheets of microfilm
Electronic 57

58. The Medical Record Patient Information Form
A document that is filled out by the patient on the first visit to the physician’s office and then updated as necessary, providing data that relates directly to the patient. 58

59. The Medical Record Medical History (Hx)
A document describing past and current history of all medical conditions experienced by the patient. 59

60. The Medical Record Physical Examination (PE) Consent Form
A record that includes a current head-to-toe assessment of the patient’s physical condition.
Consent Form
A signed document by the patient or legal guardian giving permission for treatment. 60

61. The Medical Record Informed Consent Form
A signed document by the patient or legal guardian that explains the purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed before undergoing a procedure. 61

62. The Medical Record Physician’s Orders
A record of the prescribed care, medications, tests, and treatments for a given patient. 62

63. The Medical Record Nurse’s Notes
A record of a patient’s care that includes vital signs, particularly temperature, pulse and respiration (TPR) and blood pressure (BP), and treatments, procedures, and patient’s responses to such care. 63

64. Figure Nurse’s Notes 64

65. The Medical Record Physician’s Progress Notes
Documentation given by the physician regarding the patient’s condition, results of the physician’s examination, summary of test results, plan of treatment, and updating of data as appropriate. 65

66. The Medical Record Consultation Reports
Documentation given by specialists whom the physician has asked to evaluate the patient.
Ancillary/Miscellaneous Reports
Documentation of procedures or therapies provided during a patient’s care, such as physical therapy, respiratory therapy, or chemotherapy. 66

67. The Medical Record Diagnostic Tests/Laboratory Reports
Documents providing the results of all diagnostic and laboratory tests performed on the patient. 67

68. The Medical Record Operative Report
Documentation from the surgeon detailing the operation, including the preoperative and postoperative diagnosis, specific details of the surgical procedure, how well the patient tolerated the procedure, and any complications that occurred. 68

69. The Medical Record Anesthesiology Report
Documentation from the attending anesthesiologist or anesthetist that includes a detailed account of anesthesia during surgery, which drugs were used, dose and time given, patient response, monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that occurred. 69

70. The Medical Record Pathology Report
Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue. 70

71. The Medical Record
Discharge Summary (also called Clinical Resumé, Clinical Summary, or Discharge Abstract)
Outline summary of the patient’s hospital care, including date of admission, diagnosis, course of treatment and patient’s response(s), test results, final diagnosis, follow-up plans, and date of discharge. 71

72. The Medical Record
SOAP (Subjective, Objective, Assessment, Plan): Chart Note
Subjective
Symptoms the patient feels and describes to the health care professional. Also includes the patient’s chief complaint.
Objective
Symptoms that can be observed; results of laboratory and diagnostic tests may be included. 72

73. The Medical Record
SOAP (Subjective, Objective, Assessment, Plan): Chart Note
Assessment
Interpretation of the subjective and objective findings.
Plan
Includes the management and treatment regimen for the patient. 73

74. Abbreviations 74

75. Review Quiz

76. The abbreviation for the Health Insurance Portability and Accountability Act is HIPPA.
True
False 76

77. The abbreviation for the Health Insurance Portability and Accountability Act is HIPPA.
True
False 77

78. The process of being stuck together is known as:
abate
abscess
adhesion
afferent

79. The process of being stuck together is known as:
abate
abscess
adhesion
afferent

80. A word element from which other words are formed is called:
combining vowel
prefix
suffix
word root

81. A word element from which other words are formed is called:
combining vowel
prefix
suffix
word root

82. Excision means the process of cutting out. The prefix ex- means:
to cut
process in

83. Excision means the process of cutting out. The prefix ex- means:
to cut
process in

84. The spreading process of cancer from one area of the body to another area is known as:
abnormal
efferent
malignant
neopathy

85. The spreading process of cancer from one area of the body to another area is known as:
abnormal
efferent
malignant
neopathy

86. Which branch of medicine is concerned with diseases of the kidney?
Family Practice
Internal Medicine
Nephrology
Neurology

87. Which branch of medicine is concerned with diseases of the kidney?
Family Practice
Internal Medicine
Nephrology
Neurology

88. Abate means to increase.
True
False

89. Abate means to increase.
True
False

90. The term for new disease is neopathy.
True
False

91. The term for new disease is neopathy.
True
False

92. A lack of color is called palmar.
True
False

93. A lack of color is called palmar.
True
False

94. The abbreviation for diagnosis is Dx.
True
False

95. The abbreviation for diagnosis is Dx.
True
False

96. An endocrinologist specializes in treating diseases of an allergic nature.
True
False

97. An endocrinologist specializes in treating diseases of an allergic nature.
True
False

98. The term prefix means to fix before or to fix to the end of a word.
True
False

99. The term prefix means to fix before or to fix to the end of a word.
True
False

100. Cachexia refers to a localized collection of pus.
True
False

101. Cachexia refers to a localized collection of pus.
True
False

102. Widespread occurrence of an infectious disease is called an epidemic.
True
False

103. Widespread occurrence of an infectious disease is called an epidemic.
True
False

104. The branch of medicine concerned with diseases of the lungs is pulmonary medicine.
True
False

105. The branch of medicine concerned with diseases of the lungs is pulmonary medicine.
True
False

106. A trauma surgeon would be responsible for medical repair of traumatic injuries.
True
False

107. A trauma surgeon would be responsible for medical repair of traumatic injuries.
True
False

108. Scenario
You are currently working in a doctor’s office. Most of the people your doctor sees are overweight and are seeking help from your doctor.

109. What type of physician do you work for?
anesthesiologist
bariatrician
family practitioner
gastroenterologist

110. What type of physician do you work for?
anesthesiologist
bariatrician
family practitioner
gastroenterologist

111. What is not a primary concern of bariatrics?
controlling obesity
preventing obesity
stopping obesity
treatment of obesity

112. What is not a primary concern of bariatrics?
controlling obesity
preventing obesity
stopping obesity
treatment of obesity

113. The word root bar means
a bar
bar shaped
treatment
weight/pressure

114. The word root bar means
a bar
bar shaped
treatment
weight/pressure

115. In the word bariatrician, -ician is what word part?
combining form
prefix
suffix
word root

116. In the word bariatrician, -ician is what word part?
combining form
prefix
suffix
word root

117. In the word bariatrics, the word root iatr means:
physician
one who
weight/pressure
treatment

118. In the word bariatrics, the word root iatr means:
physician
one who
weight/pressure
treatment

119. Chapter 1 Scenario
The following information was dictated by a cardiologist:
67 y/o Caucasian female c/o chest pain, shortness of breath, and dizziness
Patient appears apprehensive
Cyanotic around lips and mouth
Noted edematous abdomen

120. A cardiologist specializes in treating patients with diseases of the:
stomach and intestines
heart, arteries, veins, and capillaries
blood and blood-forming tissues
kidney and urinary systems

121. A cardiologist specializes in treating patients with diseases of the:
stomach and intestines
heart, arteries, veins, and capillaries
blood and blood-forming tissues
kidney and urinary systems