Flashcards in MT Ch. 1 Deck (44)
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4 Elements of Medical Terms
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
1
Medical record
Paper chart that documents details of patients hospital stay
2
Electronic medical record (EMR)
Digitally stored record that documents details of patients hospital stay
3
History and Physical
-patient history, exam results, initial diagnosis, and treatment plan written by admitting physician
4
Physicians orders
Complete list of care, meds, tests, and treatments physician orders for patient
5
Nurses notes
Treatment throughout the day and vital signs, specifics, patient response, and condition
6
Physician progress notes
Contains updated assessment, diagnoses, and further plans of care
7
Consultation reports
Report given by a specialist
8
Ancillary reports
Reports from various treatments received
9
Diagnostic reports
Results of diagnostic tests, usually clinical lab and medical imaging
10
Informed consent
Document signed by patient/responsible party that describes purpose, methods, benefits, and risks of procedure
11
Operative report
Diagnosis and and operation details written by the surgeon
12
Anesthesiologists report
Details of substances given, patient response, and vital signs during surgery
13
Pathologists report
Details regarding tissue removes from patient
14
Discharge summary
Documents entire hospital stay, from admitting diagnosis to final diagnosis and follow up
15
Acute Care/ General Hospitals
Diagnose and treat diseases for short time periods, offer ER
16
Specialty Care Hospitals
Provide care for specific diseases
17
Nursing Homes/Long Term Care Facilities
People who can't take care of themselves and people who need extra recovery time
18
Ambulatory Care Centers, Surgical Centers, Outpatient Clinics
Services not requiring overnight stay; from simple surgeries to testing and therapy
19
Physicians offices
Diagnostic and treatment services in a private setting
20
Health Maintenance Organization (HMO)
Prepaid system of services by primary-care physicians, specialists, and other providers
21
Home health care
Provides personal care in patients home
22
Rehab centers
Intensive PT and OT; inpatient and outpatient treatment
23
Hospices
Supportive treatment to terminally ill patients and their families
24
Organization of Body
Cells, tissues, organs, systems, body
25
Cytology
Study of cells and their function
26
Cell membrane
Outermost boundary of a cell
27
Cytoplasm
Watery internal environment of cell
28
Nucleus
Contains cells DNA
29
