Notes Flashcards
prefix
the beginning of a word, alters or modifies the meaning
can have more than one meaning
root
word or word element which other words are formed
foundation of word
combining form
a word root that a vowel can be added to
vowel doesn’t have a meaning of its own
suffix
at the end of a word to alter or modify the meaning or create a new word
can have more than one meaning
spelling
medical words of greek orgin are often difficult to spell
correct spelling is important because an ommision or addision of a single letter can change the meaning
silent beginning
gn kn mn pn ps pt
building and spelling
- if suffix begins with 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
initialism
abbreviation, formed by the initial letters of a series of words or a compound term, not pronounced as a word
pronunciation
important to pronounce correctly to convey the proper meaning
medical coding
assinging alphanumeric characters that represent the diagnosis patients have been given and the services they are to recieve.
HIPAA- mandates codes used
used to compile and report statistics
alphanumeric
refers to a character set with alphabetic characters and numerals
diagnosis codes
identify the reasons that healthcare services were provided
procedure codes
describe the types of services and procedures ordered for patients
medical records
EHR-
Electronic health record
electronic record of health-related info for an individual that is created, gathered, managed, and consulted by authorized healthcare clinicians and staff
generated and maintained within an instituition
chart/file
what a EHR contains
patient data medical history physical examination consent form informed consent form physician's orders nurse's notes physician's progress reports consultation reports ancillary/misc. reports diagnostic tests/lab reports operative report anesthesiology report pathology report discharge summary
SOAP Chart
subjective-
describes the patient’s current condition, provided by the patient, the patient’s chief complaint, presenting symptoms, the concern that brought the patient to doctor
objective-
symptoms that can be observed, seen, felt, smelled, heard, or measured by healthcare provider, vital signs, TPR and BP, and physical exam(height, weight, general appearance, condition of lungs, heart, abdomen, musculoskeletal and nervous sys, and skin),
assessment-
interpretation of the subjective and objective findings, includes diagnosis, including differential diagnosis and can rule out disease/condition
plan-
management and treatment regimen can include lab tests, radiological tests, physical or diet therapy, medications, medical and surgical interventions, patient referrals, patient teaching and follow up directions
should include current patient data, date of visit, patient’s name, DOB, age, and gender
adjective suffixes that mean pertaining
- ac
- ad
- al
- ar
- ary
- ic
- ile
- ior
- ose
- ous
- tic
- us
- y
noun suffixes that mean condition, treatment or specialist
- esis
- ia
- iatry
- ician
- ism
- ist
- osis
- y
diminutive suffixes that mean small or minute
- icle
- ole
- ula
- ule
Levels of Organization
- atoms- smallest most basic chemical unit,
- molecules- two or more atoms
- cells- basic building blocks for human body
- Tissue- grouping of similar cells that together form a specialized function
- Organs- multiple different tissues for a common purpose or function
- systems- group of different organs for a common purpose or function
Cells
membrane- allow some substances to pass through
cytoplasm- between cell membrane and nucleus
nucleus- responsible for cell’s metabolism, growth, and reproduction
stem cells- precursors of all body cells
three general properties of stem cells
- capable of dividing and renewing themselves for long periods of time
- unspecialized,
- can give rise to specialized cell types
four basic types of tissue
- epithelial- sheetlike, several layers, thick outer surfaces of the body and line body cavities, form the secreting portion of glands
- connective- most abundant and widespread, forms supporting network for organs, sheaths of muscle, and connects muscle to bone, bones to joints
- muscle-
- nerve- nuerons, excitability and conductivity and functions to control and coordinate the activities of the body
6 main functions of epithelial tissue
- protection- protects underlying tissue from mechanical damage
- sensation- sensory stimuli are detected by specialized cells in the skin, eyes, ears, nose and on the tongue
- secretion- in glands, epithelial tissue is specialized to secrete specific chemical substances such as enzymes, hormones, and lubricating fluids
- absorption- epithelial cells lining the small intestine absorb nutrients
- excretion- in the kidney excrete waste products and reabsorb needed materials from urine. sweat
- diffusion- simple epithelium (capillaries and lungs) promote the diffusion of gases, liquids, and nutrients
3 types of muscle tissue
- skeletal- voluntary striated in appreance and anchored by tendons to bones. effect skeletal movement
- smooth- involuntary, within the walls of organs and structures
cardiac- involuntary, specialied form of striated tissue found only in the heart
4 primary reference systems-
- direction- location of organs or body parts in relation to another
- planes- imaginary and divide the body into sections
- cavities- hollow space containing body organs
4 types of planes
- sagital- vertically divides right/left
- midsagital- into right/left halves
- transverse- into superior() and inferior()
- coronal/frontal- divides body at right angle to the midsagittal plane, coronal- anterior() and posterior()
2 groups of cavities
1. ventral- hollow human torso from neck to pelvis thoracic- heart and lungs abdominal- below diaphram pelvic- by bones of pelvid area 2. Dorsal- nervous sys cranial- skull spinal- bondy spinal column
