Ch.1 Intro to MT

Question 1

4 parts to a medical term

Answer 1

Word root: body system/part or describe action
Prefix: location or frequency
Suffix: condition/disease/procedure
Combining Vowel: used between root & suffix

Question 2

Define word building and describe a strategy for translating medical terms

Answer 2

Word building involves putting word parts together to create new terms. In order to translate you must be able to break down the different word parts

Question 3

State the importance of correct spelling of medical terms

Answer 3

As simple as a change/mistake in one letter can completely change the meaning of a term.

Question 4

Explain the importance of confidentiality.

Answer 4

Information that can identify the patient is considered confidential. It is at our responsibility to maintain the privacy of their information and to not release without authorization.

Question 5

The medical record details:

Answer 5

Pt day to day condition, type and time of services provided, response to treatment

Question 6

Importance of E-Medical record

Answer 6

analyzed and monitored to detect and prevent potential errors.

Question 7

History and Physical

Answer 7

written by admitting physician
details pt history, exam results, initial diagnosis, plan of treatment

Question 8

Physicians Order

Answer 8

ordered by doctor
list of care, meds, tests, treatments

Question 9

Nurse’s Notes

Answer 9

done by nursing staff
include vitals, treatment specifics, response to treatment, condition of pt

Question 10

Physicians Progress Note

Answer 10

Phys daily record of pt condition
include result of physical exam, test result summary, updated assessment/diagnosis, further plan of treatment

Question 11

Consultation Report

Answer 11

given by specialist when physician ask for patient evaluation

Question 12

Ancillary Report

Answer 12

from various treatments and therapies
i.e rehab, social services, dietetics, respiratory therapy

Question 13

Diagnostic Report

Answer 13

results of all diagnostic tests performed on pt
written by lab or medical imaging dept

Question 14

Informed Consent

Answer 14

document voluntarily signed by pt or responsible party
describe purpose, method, procedures, benefits and risks

Question 15

Operative Report

Answer 15

by surgeon detailing operation
list pre/post op diagnoses, details of the procedure, how the pt tolerated procedure

Question 16

Anesthesiologist’s Report

Answer 16

Provides details of any drugs given to patient during surgery.
Includes patient response to anesthesia and vital signs during surgery.

Question 17

Pathologist’s Report

Answer 17

A report given by a pathologist who studies tissue removed from the patient

Question 18

Discharge Summary

Answer 18

Outlines the patient’s entire hospital stay.
Includes:
Condition at admission
Admitting diagnosis
Test results or treatments
Patient’s response
Final diagnosis and follow-up plans

Question 19

Acute Care or General Hospitals

Answer 19

Provide services to diagnose and treat diseases for a short period of time.

Question 20

Specialty Care Hospitals

Answer 20

Provide care for a specific type of disease.
Examples: psychiatric hospital or children’s hospital

Question 21

Nursing Home/LTC

Answer 21

Provide long-term care for patients who need extra time to recover before going home or who cannot care for themselves

Question 22

Ambulatory Care/Surgical Center/Outpatient clinic

Answer 22

Provide services to patients who do not need overnight care.
They offer simple surgeries, therapies, or diagnostic testing.

Question 23

Physician Office

Answer 23

An individual or group of doctors providing diagnostic and treatment services in an office setting.

Question 24

Health Maintenance Organization (HMO)

Answer 24

A group of primary care physicians, specialists, and other healthcare professionals.
The HMO provides wide range of services in a pre-paid system.

Question 25

Hospices

Answer 25

Organized groups of health workers that provide supportive treatment to terminally ill patients and their families.