Introduction to Medical Assisting Vocabulary

A collection of vocabulary flashcards covering key terms, medical practice terminology, and foundational concepts from Unit 1: Introduction to Medical Assisting.

Hospice

A concept of care that involves health professionals and volunteers who provide medical, psychological, and spiritual support to terminally ill patients and their loved ones.

Indicator

An important point or group of statistical values that, when evaluated, indicates the quality of care provided in a healthcare facility.

Initiative

The ability to determine what needs to be done and to take action on your own.

Integrity

Adhering to ethical standards or right conduct standards.

Learning style

The way an individual perceives and processes information to learn new material.

Mnemonic

A learning device (e.g., an image, a rhyme, or a figure of speech) that a person uses to help him or her remember information.

Morale

Emotional or mental condition with respect to cheerfulness or confidence.

Negligence

Failure to act as a reasonably prudent person would under similar circumstances; such conduct falls below the standards of behavior established by law for the protection of others against unreasonable risk of harm.

Overlearn

To learn or memorize beyond the point of proficiency or immediate recall.

Patient navigator

A person who identifies patients' needs and barriers, then assists by coordinating care and identifying community and healthcare resources to meet the needs; also called a care coordinator.

Perceiving

How an individual looks at information and sees it as real.

Processing

How an individual internalizes new information and makes it his or her own.

Reflection

The process of thinking about new information to create new ways of learning.

Reliable

Dependable; able to be trusted.

Triage

The process of sorting patients to determine medical needs and the priority of care.

Medical assistants

Multiskilled healthcare workers who function under the direction of a licensed provider and are primarily employed in outpatient or ambulatory care facilities.

CLIA-waived tests

Tests permitted by the Clinical Laboratory Improvement Amendments that medical assistants are allowed to perform.

Allopathic

A system of medical practice that treats disease by the use of remedies, such as medications and surgery, to produce effects different from those caused by the disease under treatment; practiced by medical doctors (MDs) and osteopaths (DOs) and also called conventional medicine.

Complementary and alternative medicine (CAM)

A group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine.

Conscientious

Meticulous, careful.

Contamination

The process by which something becomes harmful or unusable through contact with something unclean.

Critical thinking

The constant practice of considering all aspects of a situation when deciding what to believe or what to do.

Demeanor

Behavior toward others; outward manner.

Detrimental

Harmful.

Holistic

A form of healing that considers the whole person (i.e., body, mind, spirit, and emotions) in individual treatment plans.

Internal Customers

These include people that you work with: coworkers, employees in other departments, administrators, etc.

External Customers

These include people outside pf your organization: patients, vendors, pharmaceutical representatives, etc

Empathy

Feeling what another person feels.

Sympathy

Acknowledging another persons pain with care or sorrow without sharing it.

Compassion

An active desire or step to help relieve someone’s suffering.

Primary Care

Smaller city or community hospitals.

Serve as the first level of contact between the community members and the hospital.

Secondary Care

Both PCPs and specialists provide care.

Larger municipal or district hospitals that provide a wider variety of specialty care and departments.

Tertiary Care

Referral system for primary or secondary care facilities.

Provide care for complicated cases and trauma.

medical centers, regional and specialty hospitals.

Ambulatory Care

Anything that can be done as an outpatient procedure.

Age of Majority

The age at which a person is considered an adult.

Alphabetic Filing

A system that utilizes the alphabet to organize things (names, topics, etc).

Alphanumeric

A system containing both numbers and letters.

Anthropometric

The measurements of size and proportion of the human body (weight and height).

Caption

A heading, title, or subtitle that records are filed under.

Compliance

Cooperation.

Meeting the standard and regulations of an organization (a medical practice).

Concise

Short and sweet. Using as few words as possible to express and idea.

Continuity of Care

A smooth continuation of care from one provider to another. Patients are able to receive adequate care without interruption or repetitive care.

Dictation

To say something for another person to write.

Direct Filing System

A system where things can be found without having to consult another person.

Electronic Health Record (EHR)

An electronic record that contains health information that is then shared to multiple health organizations.

Electronic Medical Records (EMR)

An electronic record that contains health information that is only shared within an organization.

Advance Directive

Legal document that lets a patient express their medical preferences or places another person in charge of their medical decisions in the event that they would not be able to.

E-prescribing

Using electronic software to communicate with pharmacies and send prescribing information.

Hereditary

Passed from parents to offspring.

Incidence

How often something happens.

Interface

Interconnection between systems.

Interoperability

The ability to work with other systems.

Numeric filling

A system of filling that utilizes numbers to organize the information.

Objective Information

Information that is received from the patient through testing: physical examination, laboratory testing, diagnostics testing, etc.

Obliteration

To remove or destroy all traces.

Out Guides

File sized cardboard or plastic that temporarily replaces a file that was removed.

Parameters

Guidelines/boundaries

Patient portal

A system that gives patients 24hour access to personal health information.

Prognosis

The likely outcome of a disease, including likelihood of recovery.

Provisional Diagnosis

Temporary diagnosis made before the test results.

Differential Diagnosis

A method used to differentiate between multiple diseases that share similar symptoms.

A test can differentiate between a runny nose caused by allergies, a cold, or drug use.

Quality Control

Process used to ensure the reliability of test results.

Normally consist of using manufactured samples as a baseline.

Retention Schedule

A plan for retaining health records and moving them from active to inactive.

Reverse Chronological Order

Most recent item on top, oldest item last.

Subjective Information

Information that is received from interviewing the patient.

Subsequent

Occurring later or after.

Tickler File

A chronological file that acts as a reminder that something needs to be done by a certain date.

Transcription

A written copy of dictated material

Vested

Given certain authority.

To have a special interest in.

Source Oriented Records (SOR)

Filled out based on observations and data. Sections of this form include:

Progress notes

Laboratory

Radiology

Hospital

Consultations

Problem Oriented Records (POR)

Records the problem solving system(stems taken to solve patients chief complaint). Sections of this form include:

Database(chief complaint)

Problem list

Treatment plan

Progress notes

SOAP

Acronym used to fill out progress notes:

S-subjective impressions or patient reports

O-objective clinical evidence

A-assessment or diagnosis

P-plans for further studies, treatment, or management

SOAPIER

Acronym used to fill out progress notes:

S-subjective impressions or patient reports

O-objective clinical evidence

A-assessment or diagnosis

P-plans for further studies, treatment, or management

I-interventions

E-education provided

R-response(how the patient responded)

Length of time medical records should be kept before being destroyed.

Medical records should be kept for 10yrs when in doubt.

Medicare and Medicaid medical records must be kept for 10yrs

Active record

Records of patients currently receiving treatment

Inactive record

Records of patients whom the provider has not seen in 6 months

Closed record

Records of patients who have died, moved away, or terminated their relationship with the provider.

Directed exchange

Type of HIE(health information exchange) that involves the direct exchange of info between care providers

Allows coordinated care

Query-based exchange

Type of HIE(health information exchange) that involves the providers inquiring about patient information from another healthcare provider.

Consumer-mediated exchange

Type of HIE(health information exchange) that involves the patient having access to their healthcare records