Medical Assisting Notes

Professionalism

  • Professionalism is essential in healthcare, encompassing behaviors, appearance, communication (voice, written), work ethic, and relationships.
  • Healthcare teams function as organized units where members must be courteous, knowledgeable, and respectful.
  • MAs are often the first point of contact; a positive attitude builds trust and respect.

Professional Presence

  • Essential for an effective career, including work ethic, positive demeanor, willingness to assist, cooperation, and time management.
  • Maintain personal boundaries by keeping personal relationships outside of work.
  • Adhere to professional dress and appearance standards and healthcare organization policies.
  • Follow professional communication standards always.

Healthcare Systems and Settings

  • Understanding the role and scope of practice and the healthcare team is important.
  • Respect and assist team members to provide optimal patient care.

MA Roles

  • MAs work alongside providers in outpatient or ambulatory care, performing both administrative and clinical duties.
  • Administrative tasks: greeting patients, scheduling, correspondence, and answering phones.
  • Clinical tasks: obtaining patient histories, patient education, laboratory tests, and administering immunizations.
  • Credentialing is achieved through a national certification exam.

MA Responsibilities

  • Responsibilities vary based on the setting, including administrative, clinical, or a combination of both.

Administrative Duties

  • Scheduling appointments.
  • Patient registration (demographics, payer information, compliance forms).
  • Updating and working in patient records.
  • Sending claims to insurance.
  • Collecting patient responsibility amounts (copays, coinsurance, deductible).

Clinical Duties

  • Collecting and processing lab specimens.
  • Performing diagnostic testing (EKG, spirometry).
  • Preparing and cleaning examination rooms.
  • Preparing the patient for evaluation and procedures.
  • Measuring vital signs.
  • Preparing medications and administering immunizations.

Evolving MA Role

  • Includes patient navigation and care coordination, guiding patients through the healthcare system.
  • Coordinating with the patient care team within the clinic, and externally with specialty care teams.
  • Providing helpful context about the patient’s social determinants of health and barriers to care.
  • Support the patient in being scheduled appropriately and in a timely manner with specialists.

Scope of Practice

  • Defined by education, training, and experience; does not include the practice of medicine.
  • MAs should not perform duties without proper training or certification.
  • Review duties and restrictions related to medical assisting, which vary by state.
  • Healthcare organizations must enforce state regulations, complying with stricter policies if applicable.

Variables for the Scope of Practice

  • State medical board regulations and policies.
  • Simple, routine medical tasks under licensed physician supervision.
  • Medical office’s organizational policies.
  • Common tasks include measuring height, weight, vital signs, and performing diagnostic/laboratory testing.
  • Organizational policies must adhere to state and government guidelines.

Titles

  • MAs evolved from administrative support roles to include clinical responsibilities.
  • Formalized training and certification programs have become important for the integration of medical data for government insurance.
  • Medical Assistant association was formed and recognized by 15 states in 1956.
  • The profession was recognized by the U.S. Department of Education in 1978.
  • Clinical offices often require formal training and certification.
  • Certification required for government data input into electronic records.

Additional Certifications

  • Certified medical administrative assistant (CMAA)
  • Certified phlebotomy technician (CPT)
  • Certified EKG technician (CET)
  • Certified billing and coding specialist (CBCS)
  • Certified electronic health records specialist (CEHRS)

Physician Information

  • Physicians (MD or DO) must be licensed in the state they practice.
  • Requires eight years of school: four years of undergraduate college, followed by four years of medical or osteopathic school.
  • Residency is a two- to seven-year on-the-job training period with licensed physician oversight.
  • Must pass parts I, II, and III of the U.S. Medical Licensing Examination.

Medical Doctor (MD)

  • Allopathic providers; the most widely recognized type of doctor.
  • Diagnose illnesses, provide treatments, perform surgical procedures, and write prescriptions.

Doctor of Osteopathy (DO)

  • Complete requirements like those of MDs.
  • Use osteopathic manipulative therapy in addition to modern medicine and surgery.

Midlevel Providers

  • Physician assistants and nurse practitioners.

Physician Assistant (PA)

  • Practice medicine under MD or DO supervision but can make clinical decisions after completing at least four years of college and two years of PA school.
  • Focus on a specific specialty.

Nurse Practitioner (NP)

  • Provide basic patient care services, including diagnosing and prescribing medications.
  • Require advanced academic training beyond an RN degree and have extensive clinical experience.
  • Must work under a physician's supervision in most states, but some states allow independent practice.

Nurses

  • Licensed practical nurses (LPNs) require one year of schooling and a state board examination to obtain a license.
  • Registered nurses (RNs) require more schooling (associate degree, diploma, or baccalaureate degree) and a state board examination to be licensed.
  • Licensed practical nurses (LPN) measure vital signs, administer some medications, and perform clinical care such as wound care.
  • Limited in scope of practice.
  • Registered nurses (RN) have a broader scope of practice: clinical settings, public health agencies, administrative/educational capacities.

Allied Health Professionals

  • Medical laboratory technicians: Perform diagnostic testing on blood, bodily fluids, and other specimens under the supervision of a medical technologist.
  • Medical receptionists: Check patients in/out, answer phones, schedule appointments, and perform administrative tasks.
  • Occupational therapists: Assist patients who have conditions that disable them developmentally, emotionally, mentally, or physically.
  • Pharmacy technicians: Perform routine medication dispensing functions under direct pharmacist supervision.
  • Physical therapists: Assist patients in improving mobility, strength, and range of motion.
  • Radiology technicians: Use imaging equipment to assist in diagnosing and treating diseases.

Licensure vs. Certification

  • Licensure: Mandatory for medical practice, regulated by state statutes, ensures adequate knowledge and skills.
  • Certification: Not mandatory for MAs in many states, but may be required by the government or healthcare organizations for specific services.

Health Care Licensure

  • Regulated by state statutes through medical practice acts.
  • Mandatory for physicians, controlled by state boards of medical examiners.
  • Accomplished by examination, reciprocity, or endorsement.
  • Licensure by endorsement granted on a case-by-case basis based on examinations.

Certification

  • May be required by the government or specific services.
  • Advantages: increased initial job placement, higher wages, and career advancement.

Maintaining a Certification

  • Must be maintained to stay current.
  • Ensures up-to-date information and validity to the overall profession.
  • Follow recertification process of sponsoring organization.

Inpatient and Outpatient

  • Inpatient care: Occurs when the patient is admitted to a hospital or facility.

  • Ambulatory care: Any care received in an outpatient facility.

  • Primary care clinics: Seen for routine visits, wellness checks, prevention counseling, chronic conditions, medication management, and minor acute needs.

  • Specialty care clinics: Seen for complex or severe diseases and conditions by specialists.

  • Home health: Specific types of care provided to those who cannot leave their home easily: physical, occupational, and speech therapy, and skilled nursing.

  • Must be prescribed and overseen by a provider; Typically not used on an ongoing basis for a patient but is ordered for a set period.

  • Mobile health units: Bring healthcare to underserved communities using specialized medical equipment.

  • COVID-19 pandemic expanded their use for testing and vaccinations.

  • Hospice: Comfort rather than curative efforts for terminally ill patients; outpatient or inpatient care.

Patient-Centered Medical Home (PCMH)

  • PCP coordinates treatment to ensure patients receive the required care when and where they need it and in a way they can understand.
  • Medical assistants are an integral piece of the PCMH team, assisting with direct patient care, care coordination, patient education, and administrative tasks.

Technology-Based Methods for Providing Health Care and Information

  • Telehealth and virtual visits: Healthcare delivered virtually, commonly via video call; expands access in rural areas.

Patient Portals

  • Allow patients to log in to view health information, such as test results, visit notes, and education materials.
  • May include secure messaging with the healthcare team and appointment scheduling.
  • The MA may be responsible for uploading information to the portal, as well as assisting the patient with enrolling and getting set up with an account.
  • Benefits: increased transparency about care, decreased wait times for results, and reduced demand on office staff.

Health Care Payment Models

  • Fee-for-service: Providers bill insurance and patients for each service provided with procedural codes and charges.
  • Value-based plans: Cost is more holistic; prioritizes prevention and early intervention; clinics are rewarded for keeping patients healthy.

Quadruple Aim

  • Improved patient outcomes
  • Improved patient satisfaction
  • Lower cost
  • Health care professional well-being

Other Health Care Models

  • Managed care: Healthcare provided in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals.
  • Capitation (partial or full): Patients are assigned a per-member, per-month payment based on age, race, sex, lifestyle, medical history, and benefit design.
  • Health maintenance organization (HMO): Contracts with a medical center/group to provide preventive and acute care; requires referrals to specialists and pre-authorization for procedures/admissions.
  • Preferred provider organization (PPO): More flexibility than HMO; insured person does not need a PCP or referrals; in-network providers cost less.
  • Point-of-service (POS) plan: Great flexibility for patients; self-referrals to specialists; cost depends on whether providers are within the plan’s panel.

General vs. Specialty Health Care and Services

  • General practitioners (GPs): Treat acute and chronic illnesses, provide preventive care and health education.
  • Family practitioners: Offer care to the whole family, familiar with a range of disorders and diseases.
  • Internists: Provide comprehensive care for adults, diagnosing and treating chronic conditions; may focus on pediatric or adult medicine.

Specialty Health Care Services

  • Specialists focused on diagnosing and treating diseases and disorders of specific body systems.

Specialist Care

  • Allergist: Immune system disorders, medication/food reactions, anaphylaxis, autoimmune disease, asthma.
  • Anesthesiologist: Manages pain or administers sedation during surgical procedures.
  • Cardiologist: Diseases/conditions of the heart and blood vessels.
  • Dermatologist: Skin conditions.
  • Endocrinologist: Hormonal and glandular conditions, often works with diabetes patients.
  • Gastroenterologist: Diseases of the GI tract (stomach, intestines, esophagus, liver, pancreas, colon, rectum).
  • Gynecologist: Internal reproductive system and fertility disorders.
  • Hematologist: Blood and blood-producing organs; anemia, leukemia, lymphoma.
  • Hepatologists: Diseases related to the liver, biliary tree, gallbladder, and pancreas.
  • Neonatologist: Care of newborns, specifically those who are ill or premature.
  • Nephrologist: Diseases and disorders of the kidney and its associated structures.
  • Obstetrician: Care of patients during and after pregnancy.
  • Oncologist: Treats and provides care for patients who have cancer.
  • Ophthalmologist: Diseases and conditions of the eye.
  • Orthopedist: Injuries and diseases of the bones, joints, muscles, tendons, and ligaments.
  • Neurologist: Diseases and disorders of the brain and nervous system.
  • Otolaryngologist: Diseases and conditions of the ear, nose, and throat.
  • Pediatrician: Manages newborn to adolescent health.
  • Psychiatrist: Mental disorders and conditions.
  • Radiologist: Uses and interprets imaging to detect abnormalities in the body.
  • Urologist: Disorders of the urinary tract.

Ancillary Services and Complementary Therapies

  • Providing ancillary services adds convenience for patients and revenue for the organization.
  • Urgent care: An alternative to the emergency department, costing less with a shorter wait time.
  • Appropriate for non-life-threatening acute injuries and illnesses.
  • Laboratory services: Perform diagnostic testing on blood, body fluids, and other specimens.
  • Diagnostic imaging: Using x-ray, ultrasound, MRI, and CT scan.
  • Occupational therapy: Assists patients who have conditions that disable them developmentally, emotionally, mentally, or physically.
  • Physical therapy: Assists patients in regaining mobility, improving strength, and range of motion.

Complementary Therapies

  • Acupuncture: Pricking the skin with needles to relieve pain and treat conditions.
  • Chiropractic medicine: Diagnosis and treatment through spinal manipulation and alignment.
  • Energy therapy: Clearing cellular memory promoting health, balance, and relaxation.
  • Dietary supplements: Vitamins, minerals, herbs, or other botanicals.

Team-Based Patient Care

  • Partnership between providers and patients; communication among team members essential.
  • The patient’s health is everyone’s responsibility.
  • Seamless care is provided through team collaboration.
  • Team members work at the top of their license aligning to their credentials.
  • Clinicians needed to address all needs of the patient.

Primary Care Team

  • Provider, nurse practitioner, or physician assistant.

Other Healthcare Providers

  • Mental health specialists, therapists, pharmacists, nutritionists, and dentists.

Support Staff

  • (Medical assistants, administrative staff members) also provide valuable and essential services.

Patient-Centered Medical Home (PCMH)

  • Care delivery model coordinates patient treatment through the primary care provider.
  • Goal: centralized setting that facilitates partnerships between patient, provider, and family.
  • Long-term goal: improve patient outcomes and reduce costs.

PCMH Core Function and Attributes

  • Comprehensive care: Care for the whole patient, involving all members of the healthcare team.
  • Patient-centered care: Patients and their families are core members of the team, focuses on individual needs.
  • Coordinated care: Provider-directed medical practice oversees all specialty care, hospital, home healthcare, and community services.
  • Accessible services: Tools provided through patient information web portals.
  • Quality and safety commitments: Deliver quality healthcare through evidence-based medicine; assess by collecting safety data and measuring patient satisfaction.

Accountable Care Organizations (ACOs)

  • Providers associated with a defined patient population, accountable for quality and cost of care delivered.
  • Focus on care coordination; includes multiple providers, hospitals, and specialty clinics.
  • Emphasis on public health to prevent illness: outreach programs (smoking cessation, weight loss, nutrition, online education).

Specific Roles of Team Members

  • Primary Care Provider (PCP):
    • First provider from whom a patient seeks care.
    • Main goal: coordinating preventive healthcare services.
    • Can be family practitioners, internal medicine physicians, MDs, DOs, or pediatricians.
  • Specialist:
    • Diagnoses and treats a specific area of expertise and knowledge.
    • PCPs may refer patients to specialists to diagnose or treat a specific short-term condition.
  • Physician Assistant/Physician Associate:
    • Have similar training to physicians and are licensed to practice medicine as long as a licensed doctor (MD, DO) supervises them.
    • PAs can conduct physical exams, provide preventative care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, and prescribe medicine.
  • Advance Practice Nurse:
    • Advanced practice nurses (APNs) have more education and experience than RNs and can usually perform many of the same tasks as a physician assistant.
    • Clinical nurse specialists, nurse anesthetists, nurse practitioners (NPs), and nurse midwives are common APNs.
  • Registered Nurse:
    • RNs are licensed by individual states and have an associate or bachelor’s degree in nursing.
    • RNs can perform more complicated clinical tasks and usually oversee the case management of patients who have complex chronic conditions.
  • Licensed Practical Nurse:
    • Licensed practical nurses (LPNs)—sometimes referred to as vocational nurses—are licensed by individual states.
    • LPNs usually train for approximately 1 year at a community college or vocational school, receiving a diploma or associate degree.
    • These healthcare professionals often triage phone calls, administer medications, and assist with other clinical duties in the clinical setting.
  • Pharmacist:
    • Pharmacists prepare and dispense medications prescribed by authorized providers.
    • They must be knowledgeable of individual and various combinations of medicines to educate patients on their use and answer questions about side effects.
  • Dentist
  • Therapist
    • Some clinics offer rehabilitation services.
    • Therapy services within the clinic are an added convenience for many patients and improve the communication process between providers and therapists.
  • Psychiatrist:
    • Psychiatrists are physicians who diagnose, prescribe medications for, and treat mental, behavioral, and emotional disorders.
  • Psychologist:
    • Psychologists are not physicians but have a Doctor of Psychology (PsyD) or a Doctor of Philosophy (PhD) degree.
  • Social Worker:
    • Social workers assist patients and families in times of transition or crisis.
    • They assist patients in a clinical or hospital setting with physical, emotional, and financial issues related to an illness or injury.
    • Social workers often coordinate additional services (transportation, housing, access to meals, financial resources, long-term care, hospice services).
  • Dietitian:
    • A registered dietitian nutritionist (RDN) is an expert in diet and nutrition.
    • RDNs educate patients on the connection between chronic disease and nutrition, assist with menu planning, and help low-income patients obtain healthier foods at lower prices.

Support Staff

  • Administrative and clinical staff professionals are also key players in providing the best possible experience for healthcare consumers.

Common Job Titles for Support Staff

  • Clinic coordinator
  • Medical administrative assistant
  • Clinical medical assistant
  • Medical records specialist
  • Medical billing specialist
  • Financial counselor
  • Scheduler

Patients and Family Members

  • The role of the patient and family members is more essential in patient-centered healthcare than the traditional delivery of healthcare.
  • The patient’s and family’s wants and needs are the focus areas in this type of delivery.
  • Patients decide treatments, outcomes, and need for education and counseling.
  • Effective communication is key to achieving the full participation of patients and their families.
  • Patients feel like they are in partnership with their medical provider increases satisfaction with their overall care.
  • Fewer hospitalizations, less testing, and fewer treatments are also achieved with successful patient-family-centered health care.
  • As a result, healthcare costs are also decreased.

Participate in the Transition of Care for Patients

  • Lack of communication between providers regarding histories, medication therapies, and needs increases risk of rehospitalizations, adverse events, increased spending, and poor quality of care.

To Overcome Shortfalls

  • Communicate effectively with referring providers, other providers, and the patient.
  • Educate patients regarding managing their own care and encourage them and their families to take an active role.
  • Empowering and leads to more adherence.
  • The key is excellent communication between the PCP, patient, and new/additional providers.

Resources and Procedures to Coordinate Care and Outpatient Services

  • Be cognizant of what community agencies offer and provide contact Information for services.
  • Keep a list of community resources in an easily accessible location.
  • Lists can be organized according to patient condition, age, or socioeconomic status.
  • The CDC website has resources that provide services within specified geographic locations.
  • Local hospital websites also provide information regarding outreach programs.
  • Document all information provided to the patient in the health record to promote continuity of care.

Facilitate Teamwork & Team Engagement

  • Effective teamwork and engagement are essential for a positive environment and patient satisfaction.
  • Each team member impacts patient healthcare and has specific responsibilities to complete.
  • Gossip, negative tones, and dramatic outbursts are unacceptable.
  • Professionalism and cooperative can helps to engage team members and increase patient satisfaction.
  • A healthcare is provided by a team that works well together, involving each member in the process.

Medical Terminology

  • Acquire medical terminology similar to how one learns another language via coursework, listening, and prefix, roots, suffix to expand understanding.

Do Not Use Abbreviations

  • MS, MSO4 (use Morphine MgSO4)
  • Abbreviated medication name (use full medication name Nitro - Nitroglycerin)
  • u, U, IU (use Units)
  • x3d (use mcg or microgram)
  • cc (use mL)
  • Apothecary units (use Metric units)
  • od, O.D., OD (use Daily or intended time of administration)
  • q.d, qd, Q.D, QD, q1d, i/d (use Daily)
  • q.o.d., QOD (use Every other day)
  • Q6PM (use 6 p.m. daily)
  • TIW, tw (use 3 times weekly)
  • HS (use half-strength, bedtime (hour of sleep))
  • SC, SQ, sub q (use subcutaneously)
  • IN (use intranasal)
  • IJ (use injection)
  • OJ (use orange juice)
  • @ (use at)
  • &, + (use and)
  • / (use per)
  • AD, AS, AU (use right ear, left ear, both ears)
  • OD, OS, OU (use right eye, left eye, both eyes)
  • D/C, dc, d/c (use discharge or discontinue)

Common Abbreviations and Acronyms

  • Abd - Abdomen
  • ABGs - Arterial blood gases, a.c. - Before meals
  • ACLS - Advance cardiac life support
  • Ad lib - As desired
  • ADHD - Attention deficit hyperactivity disorder
  • AKA - Above-the-knee amputation
  • AMA - Against medical advice
  • ASA - Aspirin
  • ASAP - As soon as possible
  • BE - Barium enema
  • BKA - Below-the-knee amputation
  • BM - Bowel movement
  • BMI - Body mass index
  • BP - Blood pressure
  • BPH - Benign prostatic hypertrophy
  • BPM - Beats per minute
  • BRP - Bathroom privileges
  • BSA - Body surface area, BUN - Blood urea nitrogen
  • Bx - Biopsy
  • C - Celsius, C&S - Culture and sensitivity
  • Ca - Calcium; cancer
  • CABG - Coronary artery bypass graft
  • CAD - Coronary artery disease
  • CBC - Complete blood count
  • CC - Chief complaint
  • CDC - Centers for Disease Control and Prevention.
  • Cm - Centimeter, c̄ - With
  • CMS - Centers for Medicare and Medicaid Services
  • CNS - Central nervous system
  • CP - Chest pain, CPR - Cardiopulmonary resuscitation
  • c/o - Complains of
  • COPD - Chronic obstructive pulmonary disease
  • Csf - Cerebrospinal fluid
  • CT - Computed tomography
  • Cv - Cardiovascular, CVA - Cerebrovascular accident (stroke)
  • CXR - Chest x-ray, d - Day
  • D&C - Dilation and curettage, D/C, dc - Discharge, discontinue
  • DM - Diabetes mellitus
  • DNR - Do not resuscitate
  • DOB - Date of birth
  • DTap - Diphtheria, tetanus, and acellular pertussis vaccine
  • Dx - Diagnosis
  • ECG, EKG - Electrocardiogram
  • ED - Emergency department, EEG - Electroencephalogram
  • ENT - Ear, nose, and throat, F - Fahrenheit, FBS, FBG - Fasting blood sugar/glucose
  • f/u - Follow up
  • FUO - Fever of unknown origin
  • Fx - Fracture
  • GI - Gastrointestinal
  • GTT - Glucose tolerance test
  • gt - Drop
  • GU - Genitourinary
  • GYN - Gynecology, gynecologist
  • H, hr - Hour, Hct - Hematocrit
  • HEENT - Head, ears, eyes, nose, throat
  • HF - Heart failure, Hgb - Hemoglobin
  • HIPAA - Health Insurance Portability and Accountability Act
  • HIV - Human immunodeficiency virus
  • HPV - Human papillomavirus
  • HTN - Hypertension, Hx - History
  • I&D - Incision and drainage
  • I&O - Intake and output
  • ICU - Intensive care unit
  • IUD - Intrauterine device, K - Potassium
  • KUB - Kidneys, ureters, bladder, L - Liter or left
  • lb - Pound, LLE - Left lower extremity
  • LLL - Left lower lobe
  • LLE - Left lower extremity
  • LLL - Left lower lobe
  • LLQ - Left lower quadrant
  • LMP - Last menstrual period
  • LUE - Left upper extremity
  • LUQ - Left upper quadrant
  • mg/dl - Milligrams per deciliter
  • MI - Myocardial infarction
  • mL - Milliliters, MM - Mucous membrane
  • mm Hg - Millimeters of mercury
  • MRI - Magnetic resonance imaging
  • MS - Multiple sclerosis
  • N/V - Nausea/vomiting, NB - Newborn
  • NG - Nasogastric
  • NKA/NKDA - No known allergies/no known drug allergies
  • NPO - Nothing by mouth (nil per os)
  • NS - Normal saline
  • NSAID - Nonsteroidal anti-inflammatory drug
  • OB - Obstetrics
  • OC - Oral contraceptive
  • OOB - Out of bed
  • OP - Outpatient, OT - Occupational therapy/therapist
  • OTC - Over-the-counter
  • PA - Posteroanterior, physician assistant
  • PC - After meals (post cibos), PE - Physical examination, pulmonary embolism
  • PID - Pelvic inflammatory disease
  • PMS - Premenstrual syndrome
  • PO - By mouth
  • PRN - As needed, PT - Physical therapy/therapist
  • Pt - Patient
  • R - Right, RA - Rheumatoid arthritis, RBC - Red blood cell
  • RLE - Right lower extremity, RLL - Right lower lobe
  • RLQ - Right lower quadrant
  • R/O - Rule out, ROM - Range of motion
  • RT - Respiratory therapy/therapist
  • Symptoms, T&A - Tonsillectomy and adenoidectomy
  • TB - Tuberculosis
  • TIA - Transient Ischemic Attack
  • TX - Treatment
  • UA - Urinalysis
  • URI - Upper respiratory infection
  • UTI - Urinary tract infection
  • VS - Vital signs
  • WBC - White blood cell
  • WNL - Within normal limits
  • YO, y/o - Years old

Symbols

  • > < (greater than, less than), ≥ ≤ (greater than or equal to, less than or equal to)
  • Do not use @ and &, as people can mistake them for the numeral 2. Likewise, the plus sign should not be used, because it can look like the numeral 4. When in doubt, spell it out.
  • ↑ ↑ could look like the numeral 7, ↓ ↓ could look like the numeral 1, and º could look like the numeral 0.

Meaning

  • # - Pounds, number
  • ↑ - Increase
  • ↓ - Decrease
  • ♂ - Male
  • ♀ - Female
  • ‘ - Feet
  • “ - Inches
  • ° - Degrees

Medical Word Building

Word components shared by many terms help determine the term's definition. The presence of a prefix, root, or suffix can offer a clue to the term's meaning, even if the complete definition is unknown.

Word Roots

  • Core component of many words, medical terms can have one, two or more.
  • For example, hem- means blood, and -rrhage means excessive flow. The “o” between the two creates the medical term hemorrhage, meaning excessive blood flow. Not all word roots relate to a body system or a body part

Endocrine

  • Aden - Gland
  • Pancreat - Pancreas
  • Thyr - Thyroid gland

Hematologic

  • Hem, hemat - Blood
  • Phleb - Vein
  • Thromb - Clot

Musculoskeletal

  • Arthr - Joint
  • Brachi - Arm
  • Cervic - Neck
  • Chondr - Cartilage
  • Cost - Rib
  • Crani - Skull
  • Dactyl - Finger or toe
  • Fibr - Connective tissue
  • My - Muscle
  • Oste - Bone
  • Pod - Foot
  • Sacr - Sacrum
  • Spondyl, vertebr - Vertebra
  • Ten, tendin - Tendon

Gastrointestinal

  • Abdomin - Abdomen
  • An - Anus
  • Appendic - Appendix
  • Bil, chol - Bile, gall
  • Col - Colon
  • Dent - Teeth
  • Enter - Intestines
  • Esophag - Esophagus
  • Gastr - Stomach
  • Gingiv - Gums
  • Gloss - Tongue
  • Hepat - Liver
  • Icter - Jaundice
  • Ile - Ileum
  • Lapar - Abdominal wall
  • Lingu - Tongue
  • Pancreat - Pancreas
  • Pepsia - Digestion
  • Phag - Eating, swallowing
  • Proct - Rectum
  • Splen - Spleen
  • Stomat - Mouth

Genitourinary/Reproductive

  • Andr - Male
  • Colp - Vagina
  • Cyst - Bladder
  • Gravid - Pregnant
  • Gynec - Female
  • Hyster - Uterus
  • Mamm, mast - Breast
  • Metr - Uterus
  • Nephr - Kidney
  • Ov - Ovum
  • Oophor - Ovary
  • Orchid - Testicles
  • Prostat - Prostate gland
  • Pyel - Pelvis of the kidney
  • Ren - Renal/kidney
  • Salping - Fallopian tube
  • Ureter - Ureters
  • Ur - Urinary
  • Vesic - Bladder

Respiratory

  • Bronch - Bronchial
  • Laryng - Larynx
  • Nas - Nose
  • Pleur - Pleura
  • Pneum, pneumon - Lungs, air
  • Pulmon - Lung
  • Rhin - Nose
  • Steth - Chest
  • Thorac - Thorax
  • Trache - Trachea

Integumentary

  • Derm, dermat - Skin
  • Hidr - Sweat
  • Trich - Hair
  • Onych - Nail
  • Xer - Dry

Cardiovascular

  • Angi - Blood vessel
  • Arteri, arter - Artery
  • Cardi - Heart
  • Vas - Vessel
  • Ven - Vein

Neurologic

  • Blephar - Eyelid
  • Cephal - Head
  • Cerebr - Cerebrum
  • Encephal - Brain
  • Esthesi - Sensation
  • Irid, ird - Iris
  • Mening, meningi - Membranes, meninges
  • Myel - Spinal cord, bone marrow
  • Myring - Eardrum
  • Neur - Nerve
  • Ocul, ophthalm - Eye
  • Ot - Ear

Other

  • Adip - Fat, Bio - Life
  • Carcin - Cancer, Cry - Cold
  • Dors - Back portion of the body
  • Gluc, glyc - Sugar
  • Hemi - Hernia
  • Hist - Tissue, Hydra - Water
  • Lact - Milk, Later - Side
  • Lip - Fat
  • Lith - Stone
  • Med, medi - Middle
  • Narc - Numbness, stupor, sleep, Necr - Death
  • Onc - Tumor, Path - Disease
  • Ped - Child; foot
  • Psych - Mind, Pyo - Pus
  • Pyr - Fever, heat
  • Septic - Infection
  • Therm - Heat

Combining Root Words

  • A combining form is a word root with a combining vowel
    Often, the combining vowel makes the medical term easier to pronoun
    In most cases, the combining vowel is an “o,” but it is sometimes “i” or “e.”
  • A combining form should be used when the last word root in a medical term connects with a suffix that begins with a consonant.
  • When the word root connects with a suffix that starts with a vowel, just the word root shouldBe used

Combining Form Examples

  • Col + o + -stomy = Colostomy
  • Cephal + o + -algia = Cephalagia
  • Col + o + -ectomy = Colectomy
  • Cephal + o + -dynia = Cephalodynia

Prefixes