Introduction to Medical Terminology: Basic Rules and Records

Basic Word Parts

Medical terminology is comprised of four primary word parts that function like a puzzle:

• Word Root: The foundation of the term which provides the core meaning. Often refers to a body system or action (e.g., $cardi = \text{heart}$, $cis = \text{to cut}$).
• Prefix: Added to the beginning of a word to modify meaning relative to location, number, or time (e.g., $sub- = \text{below}$, $post- = \text{after}$).
• Suffix: Added to the end of a word to indicate conditions, diseases, or procedures. Every medical term must have a suffix (e.g., $-itis = \text{inflammation}$, $-ectomy = \text{surgical removal}$).
• Combining Vowel: Usually an $o$, it connects word parts to make them pronounceable.

Rules for Combining Vowels and Forms

• Combining Form: A word root combined with its vowel, written as $root/vowel$ (e.g., $cardi/o$, $gastr/o$).
• Linking Root to Suffix: Use a combining vowel if the suffix begins with a consonant (e.g., $\text{Arthroscope}$). Do not use it if the suffix begins with a vowel (e.g., $\text{Arthritis}$).
• Linking Root to Root: A combining vowel is typically used between two word roots even if the second root starts with a vowel (e.g., $\text{Gastroenteritis}$).

Interpreting and Spelling

• Word Building: Select the correct parts and assemble them according to rules (e.g., $hypo- + derm/o + -ic = \text{Hypodermic}$, meaning pertaining to under the skin).
• Term Translation: Divide the term, define each part, and combine (e.g., $gastr/o/enter/o/logy$ is the study of the stomach and small intestine).
• Pronunciation: Stressed syllables are indicated by capital letters in phonetic spellings (e.g., $\text{pericarditis (per ih car DYE tis)}$).
• Spelling Precisions: Accuracy is vital as minor changes alter meanings, such as $abduction$ (away) versus $adduction$ (toward), or $ileum$ (intestine) versus $ilium$ (hip bone).

Plural Formations

Medical terms often follow Greek or Latin pluralization rules:

• $-a \rightarrow -ae$ (e.g., $\text{vertebra} \rightarrow \text{vertebrae}$)
• $-is \rightarrow -es$ (e.g., $\text{metastasis} \rightarrow \text{metastases}$)
• $-um \rightarrow -a$ (e.g., $\text{ovum} \rightarrow \text{ova}$)
• $-us \rightarrow -i$ (e.g., $\text{nucleus} \rightarrow \text{nuclei}$)
• $-nx \rightarrow -nges$ (e.g., $\text{phalanx} \rightarrow \text{phalanges}$)

The Medical Record

Documents the patient’s condition, services provided, and response to treatment. The Electronic Medical Record (EMR) facilitates data analysis and error prevention.

• History and Physical (H&P): Admitting physician’s initial evaluation and treatment plan.
• Physician’s Orders: List of medications, tests, and treatments.
• Nurse’s Notes: Daily record of care, vital signs, and patient response.
• Operative Report: Surgeon's details of a procedure and diagnoses.
• Informed Consent: Document signed by the patient explaining procedure risks and benefits.
• Discharge Summary: Outline of the entire hospital stay and follow-up plans.

Healthcare Settings and Confidentiality

• Settings: Include Acute Care Hospitals, Specialty Care Hospitals, Urgent Care Centers, HMOs (Health Maintenance Organizations), Hospices, and Home Health Care.
• Confidentiality: All patient information is privileged. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established federal standards for protecting medical records.