Medical Terminology: Word Structure, Spelling, Pronunciation, and Medical Records

Prefix

  • Prefix means to fix before or to fix to the beginning of a word.
  • A prefix can be a syllable or group of syllables at the beginning of a word to alter or modify its meaning or to create a new word.

Word Root

  • A root is a word or word element from which other words are formed.
  • It is the foundation of the word and conveys the central meaning.
  • It forms the base to which prefixes and suffixes are attached for word modification.

Combining Form

  • A combining form is a word root to which a vowel has been added to link the root to the suffix or to another root.
  • The vowel "o" is used more often than any other to make combining forms.

Suffix

  • Suffix means to fasten on, beneath, or under.
  • A suffix can be a syllable or group of syllables united with or placed at the end of a word to alter or modify the meaning or to create a new word.
  • Sometimes a medical word is formed by attaching a suffix directly to a prefix.
  • To break down a word to understand its meaning, you usually begin with the meaning of the suffix.

Principles of Component Parts

  • Some component parts share meanings across Greek and Latin origins.
  • Most body organ terms originate from Latin; disease terms that affect these organs originate from Greek.

Identification of Medical Words

  • Practice distinguishing among and selecting the appropriate component parts to derive the meaning of the word.

Spelling and Pronunciation: Essentials

  • Correct spelling is critical in medical terminology; a single letter change can alter meaning.
  • Medical terms of Greek origin often have silent letters or silent letters within the word.
  • Pronunciation guidance uses primary and secondary accents to convey emphasis.

Spelling: Words That Begin with Silent Letters

  • Silent beginnings include prefixes such as gn-, kn-, mn-, pn-, ps-, pt-.
  • Examples (from the guide): gnathic, knuckle, mnemonic, pneumonia, psychiatrist, ptosis.

Spelling: A Medical Term That Begins with a Silent Letter

  • Example: phlegm

Spelling: A Single Letter Can Change the Meaning of a Word

  • Example pairs:
    • abduct vs adduct (to lead away from the middle vs to lead toward the middle)
    • arteritis vs arthritis (inflammation of an artery vs inflammation of a joint)

Spelling: Prefixes and Suffixes That Are Frequently Misspelled

  • Commonly misspelled prefixes: ante-, para-, anti-, endo-, ecto-, peri-, pre-, intra-, inter-, supra-, hyper-, hypo-, intra-.
  • Commonly misspelled suffixes: -poiesis (formation), -scope (instrument for examining), -ptosis (prolapse), -scopy (visual examination), -ptysis (spitting), -tome (instrument to cut), -rrhage (to burst forth), -rrhaphy (suture), -rrhea (discharge), -rrhexis (rupture), -tripsy (crushing), -trophy (nourishment, development).

Spelling: Guidelines for Building and Spelling Medical Words

  • If the suffix begins with a 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.

Spelling: Silent Letters (Review)

  • A few examples and patterns to recognize when forming terms with silent beginnings or letters.

Spelling: A Medical Term That Begins with a Silent Letter (Review)

  • Phlegm is a representative example.

Spelling: A Single Letter Can Change Meaning (Review)

  • See above examples: abduct/adduct; arteritis/arthritis.

Formation of Plural Endings (1 of 2)

  • Singular endings can change in predictable ways for pluralization.
  • Common patterns include changes such as: -a to -ae, -ax to -aces, -en to -ina, -is to -ides, -ix to -ices, -nx to -ges, -on to -a, -um to -a, -us to -i, -a to -ae, -y to -ies, etc.
  • This covers Latin/Greek noun endings used in medical terms.

Pronunciation (1 of 2)

  • Correct pronunciation is essential for clear communication.
  • A primary accent (') marks the syllable with the strongest stress.
  • A secondary accent (") marks syllables with less emphasis.
  • Diacritics (macron, breve) indicate vowel length:
    • Macron (-) indicates a long vowel.
    • Breve (˘) indicates a short vowel.

Pronunciation (2 of 2)

  • Additional pronunciation notes and examples as provided in the course material.

Use of Abbreviations (1 of 2)

  • Abbreviation is the process of shortening a word or phrase.
  • If unclear which abbreviation to use, spell out the word instead of abbreviating.

Use of Abbreviations (2 of 2)

  • Acronyms are abbreviations pronounced as a word; initialisms are pronounced letter by letter.
  • Examples from the course:
    • AIDET: Acknowledge, Introduce, Duration, Explanation, Thank you
    • EHR: Electronic Health Record
    • HIPAA: Health Insurance Portability and Accountability Act
    • CVA: cerebrovascular accident
    • DOB: date of birth
    • BP: blood pressure
    • Dx: diagnosis

Medical Records and EHR

  • The electronic health record (EHR) is an electronic record of health information for an individual.
  • EHR contents include demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, labs, radiology images, and personal data.

Medical Records: Chart Components

  • Patient Data: information provided by the patient and updated as needed (directly related to the patient).
  • Medical History (Hx): past and current medical conditions.
  • Physical Examination (PE): head-to-toe assessment.
  • Vitals and Tests: vital signs, tests, results.
  • Medications, Immunizations, Lab data, Radiology results, and other documentation as part of the chart.
  • Discharge Summary: outline of hospital care, admission date, diagnosis, course, results, final diagnosis, follow-up plans, discharge date.

SOAP: Chart Note

  • SOAP stands for Subjective, Objective, Assessment, Plan.
  • Subjective: symptoms described by the patient; chief complaint.
  • Objective: observable signs; test results.
  • Assessment: interpretation, diagnosis, or differential diagnosis.
  • Plan: management and treatment plan.

Consent Forms and HIPAA

  • Consent Form: signed permission for treatment.
  • Informed Consent: explains purpose, risks, and benefits of a procedure; ensures patient understanding before procedures.
  • HIPAA: rules to protect privacy and ensure access, accuracy, and privacy of medical records; patients may access their records and correct errors.

Tools for Effective Communication

  • AIDET framework helps communicate with nervous or vulnerable patients:
    • Acknowledge
    • Introduce
    • Duration
    • Explanation
    • Thank you
  • SBAR framework for team communication:
    • Situation
    • Background
    • Assessment
    • Recommendation

Quick Reference: Abbreviations (selected)

  • AD: Alzheimer's disease
  • CVA: cerebrovascular accident
  • AIDET: Acknowledge, Introduce, Duration, Explanation, Thank you
  • DOB: date of birth
  • BP: blood pressure
  • Dx: diagnosis
  • EHR: electronic health record
  • HIPAA: Health Insurance Portability and Accountability Act
  • ISMP: Institute for Safe Medication Practices
  • CVS: cardiovascular system (context varies)

Summary for Last-Minute Review

  • Word structure basics: prefix, root, combining form, suffix; know how they modify meaning.
  • Spelling matters: silent letters and minor letter changes can change meaning drastically.
  • Plurals in medical terms follow Latin/Greek patterns; memorize common endings.
  • Pronunciation uses primary and secondary stress; diacritics indicate length.
  • Abbreviations require care: know acronyms vs initialisms; spell out when unsure.
  • Medical records and EHR: key contents and chart types; SOAP notes standard; HIPAA governs privacy.
  • Communication in healthcare is guided by AIDET and SBAR frameworks.
  • Key forms: Consent and Informed Consent; Discharge Summary.