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
Nursing Homes/Long Term Care Facilities
People who can’t take care of themselves and people who need extra recovery time
Ambulatory Care Centers, Surgical Centers, Outpatient Clinics
Services not requiring overnight stay; from simple surgeries to testing and therapy
Physicians offices
Diagnostic and treatment services in a private setting
Health Maintenance Organization (HMO)
Prepaid system of services by primary-care physicians, specialists, and other providers
Home health care
Provides personal care in patients home
Rehab centers
Intensive PT and OT; inpatient and outpatient treatment
Hospices
Supportive treatment to terminally ill patients and their families
Organization of Body
Cells, tissues, organs, systems, body
Cytology
Study of cells and their function
Cell membrane
Outermost boundary of a cell
Cytoplasm
Watery internal environment of cell
Nucleus
Contains cells DNA
What does a cell always have no matter it’s shape?
Nucleus, cytoplasm, cell membrane
Histology
Study of tissues
Tissues
When cells grouped together function to perform a specific activity
4 Types of Body Tissues
Epithelial, connective, muscle, nervous
Muscle tissue
- produce movement through contraction
- composed of muscle fibers
- forms skeletal muscle, smooth muscle, cardiac muscle
Skeletal muscle
Attached to bone
Smooth muscle
Found in internal organs such as intestine and blood vessels
Cardiac muscle
Found only in the heart
Epithelial tissue
- Covers and lines body structures
- can absorb substances, secrete substances, or excrete wastes
Connective tissue
- supporting and protecting tissue
- bone, cartilage, tendons, and adipose
Bone
Provides structural support for the whole body
Cartilage
Shock absorber in joints
Tendons
Connect skeletal muscles to bones
Adipose
Provides protective padding around body structures
Nervous tissue
- composed of neurons
- forms brain, spinal cord, and network of nerves