Key Concepts in Medical Terminology and Procedures

6 C's of charting

Client's Words, Clarity, Completeness, Conciseness, Chronological Order, Confidentiality

Dx

Diagnosis

-gravida

Refers to pregnancy

Cerebellum

Part of the brain that coordinates skeletal muscle activity

Greenstick fracture

Common fracture in children

Filing system for medical practices

Alphabetical

Matrix in appointment scheduling

Indicates time not available

Tickler file

A chronological file used as a reminder

Social worker

Member of the rehabilitation team responsible for the patient's emotional needs

Defamation

Pertains to any attack on a person's reputation

Good Samaritan Law

Allows medical personnel to render care in an emergency without fear of a malpractice suit

Informed consent

Must be obtained before any procedure or medication can be given to a patient

Biohazard

Anything that poses a risk to the human body or a living organism

Feedback

Verbal facial expressions or body language, such as a nod of understanding

Initial the entry

What you should do when making entries into a patient's medical record

-itis

Suffix meaning 'inflammation'

Gastrocnemius

Muscle that flexes the foot

Physician

Personnel patients should speak with about abnormal test results

Supine

Term indicating a patient is lying horizontally with the face and trunk upward

Extension

Type of motion that is a straightening of a joint, not bending

Distal

Directional term indicative of something that is farthest away from the center

Prefix location

Where the prefix of a word is located

Group insurance

Type of insurance usually sponsored and partially paid by the employer

HCPCS Codes

Number assigned for billing of supplies and equipment

Dependents

Family members, such as a spouse or children, known as under the insurance plan

Transverse plane

Divides the body from top to bottom

Sagittal plane

Divides the body into right and left

Frontal plane

Divides the body into front and back

Provider

A physician, specialist, or any person that provides medical care

Thomas Turner

Would be filed SECOND among the names

Samuel Monaco

Whose name should be filed FIRST among the names

Thomas Grenier

Whose name would be filed LAST among the names

Edema

Term that describes excessive accumulation of fluids in body tissue

Lungs

Body organ primarily affected in a person with pulmonary disease

Aorta

Largest artery of the body located along the spinal column

Myocardial infarction

Another name for a heart attack, a common disorder of the circulatory system

Central nervous system

Made up of the brain and spinal cord

Sesamoid bones

Small, rounded bones found next to joints and covered with cartilage or ligaments

Osteoblast

Builds bone

COG

Should be within the BOS when performing a transfer

Supine position

Position with the patient's shoulders parallel with the hips

Slide board

Item that assists the patient and PT aide with safe transfers when surfaces are the same height

OSHA

What requires a written schedule for cleaning?

Supine

What position would have the patient's shoulders parallel with the hips?

Peri- around

Hypo- below

Endo- inside

Antero- before

Write the meaning of the prefixes: Peri, Hypo, Endo, Antero.