Medical Terminology and Medical Records Coverage

Word Parts: Foundations

  • Medical terms are built from word parts: word root, prefixes, suffixes, and a combining vowel.
  • Word root: fundamental meaning of the term; often refers to a body system or part (e.g., cardi- = heart).
  • Prefix: added to the beginning of a term to modify meaning (location, number, time, etc.).
  • Suffix: added to the end of a term; can describe a condition, disease, procedure, or adjective form.
  • Combining vowel: usually an  linking vowel (commonly "o") placed between word parts to aid pronunciation.
  • Rules (with exceptions): combining vowels are used between two word roots and between a word root and a suffix that begins with a consonant; if the suffix begins with a vowel, the combining vowel is not used.
  • Not every medical term has a prefix or a suffix; suffixes are mandatory in every term.
  • Some terms have more than one root (e.g., osteoarthritis).
  • When a word root stands alone, the combining form is the root plus the combining vowel (written as: root / combining vowel).

Word Parts: Prefixes, Suffixes, and Combining Forms

Common combining forms (examples and meanings)

  • Bio = life
  • Carcino = cancer
  • Cardio = heart
  • Chemo = chemical
  • SISO = to cut
  • Dermato = skin
  • Entero = small intestine
  • Gastro = stomach
  • Gyneco = female
  • Hemato = blood
  • Immuno = immunity
  • Laryngo = voice box
  • Nephro = kidney
  • Neuro = nerve
  • Ophthalmo = eye
  • Auto = ear
  • Patho = disease
  • Pulmono = lung
  • Rhino = nose

Note: Some items in the transcript appear mis-typed (e.g., Auto for ear). The intended form is typically oto- for ear, but the notes reflect the transcript as written.

Prefixes: location, number, time, and other modifiers

  • A, An = without
  • Anti = against
  • Auto = self
  • Brady = slow
  • D (and Dys) = (variously) without; painful, difficult, or abnormal
  • Endo = within, inner
  • Epi = above
  • Eu = normal
  • X = outward
  • Extra = outside of
  • Hetero = different
  • Homo = same
  • Hyper = excessive
  • Hypo = below or insufficient
  • In = not or inward
  • Inter = between
  • Intra = within
  • Macro = large
  • Micro = small
  • Neo = new
  • Non = not
  • Para = beside, abnormal, or two legs of a pair
  • Per = through
  • Post = after
  • Pre = before
  • Pro = before
  • Pseudo = false
  • Re = again
  • Retro = backward or behind
  • Sub = under
  • Syn = together
  • Tachy (transcribed as "Tacky") = fast
  • Trans = across
  • Ultra = beyond
  • Un = not
  • Number prefixes: Bi = two; Hemi = half; Mono = one; Multi = many; Nulli = none; Poly = many; Quadri = four; Semi = partial or half; Tetra = four; Tri = three

Suffixes: end-of-term modifiers

  • -algia = pain
  • -itis = inflammation
  • -ectomy = surgical removal
  • -logy (logi/logic in transcript) = study of; -ologist = one who studies
  • -osis = abnormal condition
  • -osis (alternate) = abnormal condition
  • -malacia = abnormal softening
  • -megaly = enlargement
  • -oma = tumor or mass
  • -opsy = view of
  • -pathy = disease
  • -plasty = surgical repair
  • -pexy = surgical fixation
  • -centesis = puncture to withdraw fluid
  • -ostomy = surgically create an opening
  • -otomy = cutting into
  • -tome = instrument to cut
  • -gram = record
  • -graphy = process of recording
  • -meter = instrument for measuring
  • -metre (metri) = process of measuring
  • -scope = instrument for viewing
  • -scopy = process of visually examining
  • -scopic = pertaining to visually examining

Adjective suffixes (pertaining to)

  • Adjective suffixes create words that modify nouns by indicating "pertaining to". Common examples include suffixes like -ac, -al, -ic, -ous, -ary, -eal, -ine, etc.
  • Example: gastro + ic = gastric (pertaining to the stomach); gastric ulcer = ulcer found in the stomach.

Word-building rules with examples

  • Example 1: Prefix hypo (below) + combining form dermo (skin) + adjective suffix ic (pertaining to) => hypodermic (pertaining to under the skin).
  • Example 2: Gastroenterology (study of the stomach and small intestine)
    • Divide into word parts: Gastro (stomach) + O (combining vowel) + Enter (small intestine) + O (combining vowel) + Logi (study of)
    • Definition: Study of the stomach and the small intestine.

Building and Interpreting Medical Terms

  • Word building involves combining two or more word parts to form terms.
  • Key rule: understand the meaning of each part and where it belongs in the term (location and order).
  • Example: hypodermic = prefix hypo (below) + combining form dermo (skin) + suffix ic (pertaining to) → pertaining to under the skin.
  • Example: gastroenterology breakdown (as above) shows how to interpret a complex term by analyzing its parts and then assembling their meanings for a definition.

Pronunciation and Spelling of Medical Terms

  • Pronunciation varies by speaker’s background and education, but spelling must be correct.
  • If you’re unsure about spelling, ask for the term to be spelled.
  • In learning materials, bold terms are followed by phonetic spellings with the stressed syllable capitalized (e.g., pericarditis).
  • Changing a letter can change meaning (e.g., moving = adduction vs. moving toward).
  • Examples:
    • ileum (small intestine) vs ilium (hip bone) differ by one letter.
    • dys- prefix (painful/difficult/abnormal) vs dys- (different pronunciation) confusion with -dis in English terms like dislocation.

Plurals in Medical Terminology (Latin/Greek roots)

  • Many terms come from Latin and Greek; pluralization rules differ from English.
  • Examples from the transcript (note: some lines are garbled in the source):
    • Atrium -> Atria
    • Ventricle -> Ventricles
    • Vertebra -> Vertebrae
    • Thorax -> Thoracis (transcript notes this form; commonly thoraces or thoraxes in standard usage)
    • Appendix -> Appendices
    • Metastasis -> Metastases
    • Phalanx -> Phalanges
    • Ganglion -> Ganglia
    • Ovum -> Ova
    • Nucleus -> Nuclei
    • Biopsy -> Biopsies
  • Important: memorize that some endings change in predictable ways, while others vary with root origin.

Abbreviations and Medical Records

Use of abbreviations

  • Abbreviations save time but can be confusing.
  • Always spell out terms when there is potential for confusion.
  • Use only approved, facility-wide abbreviations; do not create personal abbreviations.

The medical record (hospital setting)

  • Documents details of a patient's hospital stay: day-to-day condition, services provided, patient response to treatment.
  • All personnel who interact with the patient must complete the relevant reports.
  • Medical Records Department ensures documents are present, complete, signed, and in a specific order.
  • Electronic Medical Records (EMR): software for entering patient information digitally.
  • Benefits of EMR: detect/prevent errors, easy access and sharing among providers, reduced duplication of tests, fewer medication errors.

Common elements of the medical record

  • History and Physical (H&P): written by admitting physician; includes patient history, exam results, initial diagnosis, plan of treatment.
  • Physician's orders: medications, tests, treatments requested by physician.
  • Nurse's notes: vital signs, treatments, patient responses, overall condition.
  • Physician's progress notes: daily physician record; exam results, test results, assessment, plan.
  • Consultation reports: notes by specialists consulted at physician's request.
  • Ancillary reports: therapies and services (PT/OT/speech, social work, respiratory therapy, dietetics).
  • Diagnostic report: results of laboratory tests and imaging.
  • Informed consent: document describing purpose, method, procedure, benefits, and risks; patient authorization.
  • Operative report: surgeon's account of an operation, pre/postoperative diagnoses, details of the procedure, patient tolerance.
  • Anesthesiologist's report: drugs given, patient response, vital signs during anesthesia.
  • Pathologist's report: findings on tissues removed during surgery.
  • Discharge summary: overview of hospital stay, admission diagnosis, tests/treatments, response, final diagnosis, follow-up plans.

Healthcare Settings and Delivery Environments

  • Acute care/general hospital: diagnosis and treatment for a short period.
  • Specialty care hospital: care focused on a specific disease type (e.g., psychiatric hospital, children's hospital).
  • Nursing home / long-term care facility: long-term care; patients needing extended recovery time or assistance.
  • Urgent care centers: walk-in facilities providing immediate care when primary care is unavailable or unnecessary.
  • Ambulatory care center / outpatient clinic: facilities for procedures and testing not requiring overnight stay.
  • Physician's office: diagnostic and treatment services in office settings.
  • Health Maintenance Organization (HMO): prepaid system with primary care physicians and specialists.
  • Home health care: nursing, therapy, personal care, or housekeeping in the patient’s home.
  • Rehabilitation centers: physical and occupational therapy in inpatient or outpatient settings.
  • Hospice: supportive care for terminally ill patients and families, not limited to a six-month prognosis.

Confidentiality and HIPAA

  • All patient information is privileged; healthcare workers have moral and legal responsibility to protect privacy.
  • Releasing information requires patient authorization.
  • HIPAA (Health Insurance Portability and Accountability Act) of 1996 sets federal standards for protecting medical records and health information.
  • If privacy notices were signed when seeing a physician or staying in the hospital, those facilities are following HIPAA guidelines.

Connections, Implications, and Practice

  • Terminology foundations connect to broader principles of anatomy, pathology, and clinical care.
  • Understanding word parts and combining rules helps in both constructing terms and interpreting medical language accurately.
  • Clear documentation (medical records) supports patient safety, continuity of care, and legal compliance.
  • Ethical and legal responsibilities under HIPAA reinforce the need to protect patient privacy in all settings.
  • Practical takeaway: always verify suffix meanings, confirm pronunciation and spelling, and follow facility-approved abbreviations to minimize medical errors.
  • Real-world relevance: accurate term construction supports correct diagnoses, treatments, reporting, and billing in healthcare systems.

Note on transcript quality: Some sections of the transcript appear garbled or contain minor inaccuracies (e.g., oto vs auto vs other forms; some pluralization rules). The notes above reflect the intended standard meanings and examples as presented in the source, with clarifications where commonly accepted terminology differs. If you’re using these notes for study, you may want to cross-check specific terms against a reliable medical terminology reference for exact spellings and plurals.