Med Term

DM

DM stands for diabetes mellitus, a disease in which the body has difficulty managing and regulating levels of sugar in the bloodstream.

FAS

FAS stands for fetal alcohol syndrome, a group of mental or physical defects that can develop in an unborn baby from the mother’s alcohol consumption during pregnancy.

FBOA

FBOA stands for foreign-body obstructed airway, an airway that has been obstructed by a foreign object, usually because the object has been swallowed.

FUO

FUO stands for fever of unknown origin, a diagnosis noted when a patient has a temperature of 101ºF or more several times over the course of three weeks and doctors cannot determine the cause.

Fx

Fx stands for fracture, a specific way that a bone has been broken.

combining form - a root word with an added vowel at the end in order to make it easier to pronounce when combined with a suffix that begins with a consonant

prefix - a word part added to the beginning of a word, and often used to indicate location, time, or present status

root words - word parts that carry the essential meaning of a word, and cannot be broken down into smaller parts

angi(o) - Angi means blood vessel.

Angi(o) is its combining form.

For example, angiography is a technique for producing images of the insides of blood vessels.

arteri(o) - Arteri means artery.

Arteri(o) is its combining form.

For example, arteriosclerosis is a hardening of the arteries.

arthr(o) - Arthr means joint.

Arthr(o) is its combining form.

For example, arthritis is the inflammation of one or more joints.

Audi -Audi means sound or to hear.

Audi(o) is its combining form.

For example, an audiologist is a doctor who specializes in hearing.

bronch(i)(o) - Bronchi means the air passages of the lungs.

Bronch(i)(o) is its combining form.

For example, bronchitis is an inflammation of the air passages of the lungs.

carcin(o) - Carcin means an abnormal growth or tumor. It can also mean an open sore on or in the body, called an ulcer.

Carcin(o) is its combining form.

For example, a carcinoma is a type of cancer, or disease resulting from abnormal cells multiplying uncontrollably to grow tumors in the body.

cardi(o) - Cardi means heart.

Cardi(o) is its combining form.

For example, cardiomyopathy is a disease or deterioration of the muscle tissue of the heart.

crine - Crine means secrete or release.

For example, endocrinology is the study of how organs in the body secrete or release chemicals throughout the body.

cyt(o) - Cyt means cell.

Cyt(o) is its combining form.

For example, cytology is the study of cells. Cells are the most basic units of life.

derm(a)(t)(o)

Derm means skin.

Derm(a)(t)(o) is its combining form.

For example, dermatologists are medical doctors who specialize in the health of the skin.

electr

Electr means electricity.

For example, electrocardiography is the measurement of electrical impulses in the heart.

encephal(o)

Encephal means brain.

Encephal(o) is its combining form.

For example, encephalitis is an inflammation of the brain.

gastr(o)

Gastr means stomach.

Gastr(o) is its combining form.

For example, a gastric bypass is a type of weight-loss surgery in which the stomach is divided into smaller sections.

glyc(o)

Glyc means sugar, also known as glucose.

Glyc(o) is its combining form.

For example, hypoglycemia refers to low levels of glucose in the blood.

hemat(o)

Hemat means blood.

Hemat(o) is its combining form.

For example, hematology is the study of blood and blood disorders.

hepat(o)

Hepat means the liver.

Hepat(o) is its combining form.

For example, hepatitis is an inflammation of the liver.

hist(o)

Hist means tissue. Tissues are collections of cells.

Hist(o) is its combining form.

For example, histology is the study of tissues.

lymph(o)

Lymph means a colorless fluid containing white blood cells that drains into the bloodstream.

Lymph(o) is its combining form.

For example, lymphoma is a cancer of the lymph nodes and lymph cells.

my(o)

My means muscle.

My(o) is its combining form.

For example, myopathy is a disease of the muscle tissue.

neur(o)

Neur means nervous system, which is the entire nerve apparatus of the body.

Neur(o) is its combining form.

For example, neurology is the study of the nervous system.

onc(o)

Onc means tumor.

Onc(o) is its combining form.

For example, oncologists study tumors and cancer.

opthalm(o)

Ophthalm means eye.

Opthalm(o) is its combining form.

For example, ophthalmologist refers to a medical professional who studies eyes and sight.

oste(o)

Oste means bone.

Oste(o) is its combining form.

For example, osteoporosis is the thinning and loss of bone over time.

path(o)

Path means disease.

Path(o) is its combining form.

For example, pathology is the study of disease.

pharmac(o)

Pharmac means drug or medication.

Pharmac(o) is its combining form.

For example, pharmacology is the study of drugs and medication.

phleb(o)

Phleb means veins.

Phleb(o) is its combining form.

For example, phlebotomists are healthcare professionals who draw blood from veins.

physi(o)

Physi means nature, origin, or function.

Physi(o) is its combining form.

For example, physiology is the study of the function of living organisms.

pulmon(o)

Pulmon means lungs.

Pulmon(o) is its combining form.

For example, pulmonary embolism is a blockage in an artery leading to the lung.

thoraci(c)

Thoraci means chest.

Thoraci(c) is its combining form.

For example, thoracic means relating to the chest.

a- or an-

A- or an- means no, or without.

For example, asepsis means without pathogens, or the state of being free from pathogens.

ab-

Ab- means away from.

For example, abduction is movement of a limb away from the midline of the body.

ad-

Ad- means toward.

For example, adduction is movement of a limb toward the midline of the body.

aut(o)-

Aut- means self.

Aut(o) is its combining form.

For example, an autograft is a surgery using one’s own skin to make the repair.

brady-

Brady- means slow.

For example, bradycardia refers to a slow heartbeat

chem(o)-

Chem- means chemistry or drug.

Chem(o) is its combining form.

For example, chemotherapy is a drug treatment used to treat cancer.

dia-

Dia- means complete or through.

For example, diagnosis refers to a complete state of knowledge for the purposes of identifying a disease.

dis-

Dis- means to separate or take apart.

For example, dissection refers to cutting open an organism to observe its internal structures.

Dis- can also be used to mean:

• lack, as in distrust or disorientation

• reversal, as in disconnect

dys-

Dys- means abnormal or painful.

For example, dysentery is the name of a disease that causes inflammation of the intestine, and is quite painful.

endo-

Endo- means inside or within.

For example, endoscopy is a method of visualizing internal organs with a camera.

epi-/exo-

Epi- and exo- both mean outside or outside of.

For example, epicardium is the outer heart tissue, and exoskeleton is a skeletal structure found on the outside of an organism

eu-

Eu- means good or normal.

For example, euglycemia refers to a normal level of blood sugar.

hyper-

Hyper- means above or above normal.

For example, hypertension refers to high blood pressure.

hypo-

Hypo- means under or below normal.

For example, hypoglycemia refers to low blood sugar.

inter-

Inter- means between or among.

For example, intercellular means between or among cells

lyso-

Lyso- means dissolve or dissolution.

For example, lysosomes are parts of cells that dissolve or break down waste.

macro-

Macro- means large.

For example, macrophages are large cells.

mal-

Mal- means bad or ill.

For example, malignant refers to a growth that is cancerous, made up of abnormal cells multiplying uncontrollably.

micro-

Micro- means small.

For example, a microscope is a tool used by scientists to view small body parts, such as tissues and cells.

mono-

Mono- means single or one.

For example, a monolayer refers to a structure with only one layer.

neo-

-ac, -al

-ac and -al mean of or pertaining to.

For example, cardiac means of or pertaining to the heart, and abdominal means of or pertaining to the abdomen.

-algia

-algia means pain.

For example, myalgia refers to muscle pain.

-cidal, -cide

-cidal and -cide mean killing.

For example, fungicide is a substance that kills fungi.

-crine

-crine means to secrete, or to produce and release a substance.

For example, endocrine refers to the body system that secretes substances into the bloodstream.

-cyte

-cyte means cell, which is the smallest building block of the body.

For example, leukocytes are white blood cells.

-ectomy

-ectomy means removal of.

For example, mastectomy refers to the surgical removal of breast tissue.

-emia

-emia means blood condition.

For example, anemia is a decrease in the number of red blood cells.

-globin

-globin means containing protein.

For example, hemoglobin is a protein in red blood cells that allows blood to carry oxygen.

-gnosis

-gnosis means knowledge.

For example, diagnosis refers to the ability to characterize and identify a disease or disorder.

-gram

-gram means record or picture.

For example, a cardiogram is a visual representation of a heart beat.

-graph

-graph means an instrument used to record data or a picture.

For example, an electrocardiograph is a tool used to record heartbeats.

-ia and -iasis

-ia and -iasis mean condition.

For example, bradycardia is a condition in which the heart beats slowly, and psoriasis is a skin condition.

-iatry

-iatry means a field in medicine.

For example, psychiatry refers to a medical field that deals with psychological disorders.

-ic

-ic means pertaining to or characterized by.

For example, a narcotic is a class of drugs characterized by its ability to relieve pain and produce stupor, or unconsciousness.

-ism

-ism means condition or process.

For example, an embolism is a condition in which a mass, called an embolus, is blocking a blood vessel.

-itis

-itis means inflammation or infection.

For example, tonsillitis is an inflammation of the tonsils.

-lepsis/-lepsy

-lepsis and -lepsy mean an attack or seizure.

For example, epilepsy is a condition characterized by seizures.

-logist

-logist means specialist in the field.

For example, an oncologist is a physician who specializes in studying cancer.

-logy

-logy means study or practice of a certain field.

For example, oncology is the study of cancer.

-lysis

-lysis means destruction or separation.

For example, paralysis refers to the inability to move or control certain body parts.

-meter

-meter means an instrument used to measure.

For example, a thermometer measures temperature.

-oma

-oma means tumor, collection, or mass.

For example, a hematoma is a collection of blood outside the blood vessels.

-opsy

-opsy means to view.

For example, a biopsy is a view of cells extracted from a person.

-osis

-osis means condition or disease.

For example, neurosis refers to a mental disorder.

-pathy

-pathy means disease or disorder.

For example, neuropathy is a disease that affects the nerves.

-phobia

-phobia means a fear of.

For example, agoraphobia is the fear of crowds and people.

-plasty

-plasty means surgical repair.

For example, rhinoplasty is the surgical repair of the nose.

-rrhea

-rrhea means discharge or flow.

For example, rhinorrhea is the excessive discharge of mucus from the nose.

-rrhage

-rrhage means bursting.

For example, a hemorrhage is heavy bleeding due to the breaking or bursting of blood vessels.

-scope

-scope means an instrument used for viewing or measuring.

For example, a stethoscope is used to listen to a person’s heartbeat.

-scopy

-scopy means the use of an instrument for viewing.

For example, an endoscopy is the procedure of viewing the esophagus or stomach.

-sis

-sis means a state of, or condition.

For example, pneumoconiosis is a lung disease caused by the inhalation of dust.

-(s)tomy

-(s)tomy means the creation of an opening.

For example, a colostomy is an opening created from the colon (large intestine) to the outside of the body to permit the passage of stool.

-trophy

-trophy means nourishment or development.

For example, hypertrophy is the enlargement of organs or tissues via an increase of size in their component cells.

-y

-y means condition or process of.

For example, surgery is an invasive medical technique used to diagnose or treat disorders or conditions.

alphabetic index

a content list for a reference work organized by the first letter of each entry

ICD-10-CM

tenth revision of the ICD code set

insurance reimbursement

the process of receiving payment from an insurance company for a covered benefit

nomenclature

an organized system of words for use in a particular field

tabular list

a category grouping of items

International Classification of Diseases-10th Revision-Procedure Classification System (ICD-10-PCS)

a separate procedure code system in the ICD-10 clinical vocabulary system

procedure code

a code assigned to a particular medical service or procedure

International Classification of Diseases for Oncology (ICD-O)

an extension of the ICD for use in classifying neoplasms

oncology

the medical specialty that focuses on cancer

neoplasm

an abnormal growth of cells that may or may not form a tumor (solid mass), and may or may not be malignant (cancerous)

Health Care Procedure Coding System (HCPCS)

a diagnosis and procedure code nomenclature used for outpatient billing in the US

HCPCS Level I

a clinical coding system used to describe medical and surgical procedures performed by healthcare providers that is identical to the Current Procedural Terminology (CPT) system of the American Medical Association

HCPCS Level II

a collection of codes for services that are not found in the CPT system, including, for example, non-physician services

Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)

a multinational, multilingual, comprehensive medical nomenclature covering all aspects of medicine

Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5)

the current version of the DSM, a publication of the American Psychiatric Association (APA) used as the primary resource in the US to classify and diagnose mental disorders

mental disorder

a condition in which a person’s thoughts, feelings, and/or behaviors cause distress or impair the ability to function

substance abuse

a pattern of use medications or substances that are not part of an approved medical plan or treatment

nursing vocabulary

a nomenclature system used to communicate nursing strategies, protocols, and procedures

medical coding

the process of assigning nomenclature codes to patient data obtained by examining medical records

medical transcriptionist

a specialist who creates a text-based medical record from a voice recording

medical coder

a specialist in medical coding

medical biller

a professional who prepares and submits insurance claims for a provider based on a medical coder’s work

medical claims examiner

a health insurance professional who examines submitted medical claims to ensure that they are valid and qualify for payment

explanation of benefits

a form created by the insurance company to explain what charges were covered, denied, or need more documentation based on the claims submitted by the physician’s office

medical record

the lifetime record of a patient’s health, health problems, and medical care at a particular institution

medical history

a patient’s health history, including information such as allergies, medications being taken, past medical history (PMH, e.g., prior illnesses and surgeries), social history (SH, e.g., occupation and habits such as smoking, exercise, and alcohol use), and family history (FH)

medical encounter

a single patient-provider visit, during which the patient’s chief complaint (CC) and the history of the present illness (HPI) are discussed, a physical examination (PE) is performed, and a diagnosis (DX) and treatment (TX) plan are made

personal health record

a medical record that is maintained by the patient for personal benefit

American Health Information Management Association (AHIMA)

not-for-profit professional organization serving the educational, credentialing, networking, and advocacy needs of health information management (HIM) professionals

data quality management model

an AHIMA concept that standardizes data storage, maintenance, and organization according to ten quality characteristics

data quality characteristics

the ten AHIMA data quality characteristics that require data to be accurate, accessible, comprehensive, consistent, current, defined, granular, precise, relevant, and timely

history

refers to a patient's past medical history, as well as the history of the present illness

exam

includes both a physician's physical examination of a patient, as well as any test results

medical decision making

component of the health record that substantiates the care provided, supports reimbursement for each procedure, and serves as a legal document that validates the treatment provided for each diagnosis

electronic health records (EHRs)

health records that allow real-time communication, reporting, and record keeping through electronic transmission

hybrid health records

medical records that incorporate elements of paper-based records and electronic records

source-oriented medical record

a record that is organized by data source or subject

problem-oriented medical record

a record that organizes data by problem, and uses four categories: a database of all objective information, a numbered problem list, initial treatment plans, and progress notes

clinical data repository (CDR)

a special database that manages healthcare data from different sources such as labs, pharmacies, and radiology networks

electronic medication administration record (EMAR)

an EHR system for medication management that uses the CDR database

patient care charting system

a type of EHR that records progress notes and assessments

hospital information system (HIS)

a computerized management solution that handles all aspects of a hospital’s operations, including financial and medical operations

Certification Commission for Health Information Technology (CCHIT)

a nonprofit organization with the mission of accelerating the adoption of information technology (IT) in healthcare, it measures and certifies the effectiveness of EHR products based on predefined criteria

pay for performance (P4P)

performance-oriented incentives for hospitals and physicians to improve the quality of patient healthcare

Centers for Medicare and Medicaid Services (CMS)

a US government organization that oversees services for the federally sponsored Medicare and Medicaid insurance programs

Dental Office Reference Manual (DORM)

a reference manual that provides information about administrative policies relating to a dental practice

Dental Periodicity Schedule

a schedule that recommends certain oral health services for children according to age

dental extraction

the removal of primary teeth

electronic prescribing

the digital authoring, transmission, and filling of physician medication prescriptions, it is intended to reduce errors, time, and costs

electronic data interchange (EDI)

the digital exchange of structured data between computer systems; reduces errors and can be used, for example, for sending prescriptions to a pharmacy

intranet

a closed network of computers within a facility or organization

interoperability

the ability to share data between multiple systems without altering the meaning of the data

health information exchange (HIE)

the digital exchange of healthcare data between different organizations in order to improve patient care, and reduce costs and errors

notice of privacy practices (NPP)

a legally required notice that healthcare providers and plans must distribute to their patients that outlines how their protected health information is used and disclosed, and the rights the patient has

Regional Health Information Organization (RHIO)

a regional health information exchange that centralizes data from multiple facilities, including hospitals and clinics

Health Insurance Portability and Accountability Act (HIPAA)

legislation that provides guidelines on maintaining patient privacy and confidentiality through standardized methods of handling healthcare data

patient confidentiality

protection from private healthcare information being released without prior permission

privacy rule

a part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer

protected health information (PHI)

any information about a person’s health, healthcare, or payment for health services that can be linked to a specific patient compliance

health information management (HIM)

the management of patient healthcare data of all types

information technology

the processes needed to assimilate, organize, maintain, and store patient healthcare data

health informatics

a branch of health information management that uses computer systems to gather, organize, maintain, and store patient healthcare data

traditional health record

a medical chart stored and maintained in paper format

electronic medical record (EMR)

digitally stored and accessed patient records that allow real-time communication, reporting, and recordkeeping through electronic transmission; also called electronic health records (EHRs) or computer-based patient records (CPRs)

hybrid health record

a medical record that incorporates elements of paper-based records and electronic records

alphabetical filing system

a method of organizing health records according to each patient’s surname

numerical filing system

a method of organizing health records according to a unique patient identification number

alphanumeric filing system

a method of organizing health records by combining the first two letters of the patient’s surname with a numerical identifier

out guide

a card placed in a collection of paper files to indicate that a file has been removed

requisition

a written request for a health record

quality management

the process of planning, controlling, and improving the quality of a product or system

deficiency slip

a report generated to notify staff that a medical record is missing required information

index

a database that contains pertinent healthcare information that can be used for research, healthcare quality control, or statistical purposes

master patient index

the primary index used for HIM recordkeeping, which includes a unique record for each patient within a healthcare organization

physician index

a database that records the physician associated with each patient, diagnosis made, and procedure performed at a healthcare organization

registry

a database of information concerning births, deaths, admissions, and discharges

Centers for Disease Control and Prevention (CDC)

a United States government organization that seeks to promote healthy behaviors and the prevention of disease, injury, and disability

World Health Organization (WHO)

a global organization, created by the United Nations, that provides global leadership on health, health research, and health policy

cancer and trauma registries

compilations of healthcare data on different types of cancers and traumatic events

Centers for Medicare and Medicaid Services (CMS)

a United States government organization that administers the Medicare and Medicaid health insurance programs

birth certificate completion

the process of fully completing an infant’s birth certificate

statistical and research services

data analysis services provided for health information professionals who are conducting medical studies or tracking diseases

medical transcription

the process of creating a text-based medical record from a voice recording

medical coding

the process of assigning standardized codes to patient data obtained by examining medical records

medical billing

the process of generating claim forms that list diagnosis and procedure codes, charges, and patient demographic information for reimbursement purposes

health data security

the process of ensuring that medical records are unaltered, readily accessible, and used legitimately

Health Insurance Portability and Accountability Act (HIPAA)

a law governing the portability of health insurance when workers change jobs, the standards for electronic healthcare transactions, and the security and privacy of health data

Privacy Rule

a part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer

patient confidentiality

the right to expect that healthcare information will not be disclosed without a patient’s authorization

breach of confidentiality

disclosure of patient information without prior written consent

compliance

the process of adhering to state and federal laws

protected health information (PHI)

any information about a person’s health, healthcare, or payment for health services that can be linked to a specific patient

Department of Health and Human Services (HHS)

a United States government organization that establishes guidelines for health information management compliance

Office of the Inspector General (OIG)

investigates abuse, fraud, waste, and mismanagement within a government organization

American Health Information Management Association (AHIMA)

a not-for-profit professional organization serving the educational, credentialing, networking, and advocacy needs of health information management (HIM) professionals

hazard

something that presents a danger or risk of injury

hazardous material

a substance that has the potential to cause harm

biohazard

a biological substance, such as blood or another bodily fluid, that has the potential to transmit disease

carcinogen

a substance known to cause cancer

other potentially infectious materials (OPIMs)

a category of possible biohazards other than blood, including tissues and bodily fluids, such as semen, vaginal secretions, and spinal fluid, that have been defined by the US Occupational Safety and Health Administration (OHSA)

accident

any unplanned occurrence that has potentially negative consequences

infectious disease

an illness caused by an infectious particle that can be transmitted from person to person

Healthcare-associated infection

an infection that a patient acquires while being treated at a healthcare facility for a different ailment

side effect

an unintended, often problematic outcome of a treatment

adverse effect

an unintended harmful effect of a medical treatment

laboratory medicine

the analysis of samples, such as bodily fluids, tissues, or chemicals, for diagnostic or research purposes

drug

a substance used to treat a symptom (complaint) or to treat or prevent a disease

sharps

medical equipment, such as needles or scalpels, that can puncture or cut healthcare workers; used sharps may transmit biohazards

sharps container

a rigid, well-labeled plastic container designed to safely hold sharp objects for disposal

CT scan

a computed tomography scan; a scan that uses X-rays to create 2-D and 3-D images of parts of the body

radiation

a form of energy characterized by the passage of particles or waves through a medium; e.g., light, heat, radio waves, and X-rays

X-ray

a form of electromagnetic radiation that can be used for medical imaging and therapeutic purposes

Centers for Disease Control and Prevention (CDC)

a division of the federal Department of Health and Human Services that collects data on patient and healthcare worker safety, and promotes safety practices to protect patients and workers

Occupational Safety and Health Administration (OSHA)

a division of the US Department of Labor whose mission is to ensure safe and healthful working conditions

material safety data sheet (MSDS)

a document that provides information on the hazards, handling procedures, and safe disposal of a chemical

personal protective equipment (PPE)

a category of clothing that protects the wearer from coming into contact with infectious material

safety procedure

a series of steps put in place to prevent accidents

standard precautions

a set of practices used to help prevent the transmission of infections; include assuming that everyone is potentially infectious, wearing personal protective equipment, and disposing of sharps properly

pathology

the study of disease and the way it affects the functions of the body

disease

a condition that affects the normal functioning of the body; in some cases known as a disorder

symptom

the effects of a disease that a person feels, such as aches and pains

communicable disease

a disease that is contagious

non-communicable disease

a disease that is not contagious

pathologist

a doctor who studies diseases and causes of death

geneticist

someone who studies how traits and genes are passed down

oncologist

a doctor who specializes in treating cancer

psychiatrist

a doctor who specializes in treating emotional and behavioral issues

immunologist

a doctor who studies how well the body can fight against diseases and infections

-algia

pain

-dynia

pain

-ectasia, -ectasis

dilatation, or the stretching of a body structure

-edema

swelling

-itis

inflammation

-emesis

to vomit, or vomiting

esthesi(o)

feeling or sensation

-malacia

soft, softening

-megaly

enlargement

-oid

resembling

-penia

deficiency

-rrhage, -rrhagia

excessive bleeding or hemorrage

-rrhea

flow or discharge

-rrhexis

rupture

-spasm

involuntary contraction, twitching, or cramp

-therapy

treatment

pharmac(o), pharmaceut(i)

drugs or medicine

therapeut(o)

treatment

algesi(o)

sensitivity to pain

chem(o)

chemical

cry(o)

cold

narc(o)

stupor

therm(o)

heat

surgery

the treatment or investigation of disease through cutting or manipulation of the body

surgeon

a physician who specializes in surgery

-scope

a surgical instrument used for viewing and in diagnostic procedures

-ectomy

a surgical procedure involving an excision, or cutting out

-tome

instrument used for cutting

-stomy

forming an opening or joining two previously unconnected organs

-tomy

incision, or cutting into tissue

-tripsy

intentional surgical crushing of a part of the body

-centesis

a surgical puncture to aspirate or remove fluid

aspirate

to remove a fluid by vacuum suction

-ectomy

a surgical procedure involving an excision, or cutting out

excision

a surgical procedure of removal or cutting out

-lysis

the process of loosening, freeing, or destroying

-pexy

the surgical fixation (fastening in a fixed position)

-plasty

surgical repair

-rrhaphy

suture (uniting a wound with stitches)

-stasis

stopping, controlling

disease

any condition not caused by an injury that causes the body to work incorrectly

diagnosis

the identification of a disease or disorder by the evaluation of its history, symptoms, physical signs, and test results

misdiagnosis

a diagnosis that is later discovered, based on new evidence, to have been incorrect

prognosis

the predicted outcome of a disease

chronic

a term used to describe the time scale and/or severity of a disease or disorder, which indicates a slow onset, usually slow course (long duration), and low severity

acute

a term used to describe the time scale and/or severity of a disease or disorder, which indicates a rapid onset, usually fast course (short duration), and often intense severity

sign

an observable effect of disease that medical professionals can visualize or detect, such as swelling or color changes

symptom

an effect of disease or disorder as experienced by the patient (e.g., aches and pains, weakness, etc.)

blood pressure

the force exerted by blood against the walls of the blood vessels as it circulates throughout the body

diastolic pressure

the blood pressure measured during diastole, which is that phase of heart activity when it is resting and filling with blood for the next systole

systolic pressure

the blood pressure measured during systole, which is that phase of heart activity when it is contracting and actively pumping blood out

pulse

the rhythmic expansion of an artery that occurs as the heart beats

respiration rate

number of breaths per minute

endoscope

illuminated instrument for the visualization of the interior of a body cavity or organ

fluoroscope

instrument that provides real-time imaging of the motion of internal structures through the use of X-rays and a fluorescent screen

microscope

an instrument that uses shaped lenses to magnify and study microscopic samples

stethoscope

an instrument used to listen to internal body sounds such as the heartbeat or intestinal activity

radiograph

a diagnostic image, or X-ray, created by applying radioactive X-rays to a portion of the body

tympanic thermometer

thermometer with a specially designed tip that is placed into the external opening of the ear canal to obtain a body temperature reading

calibration

the process of adjusting an instrument to ensure its accuracy

microscopy

inspection with a microscope

biopsy

a diagnostic procedure in which tissue cells are surgically removed from a patient and examined for the presence of disease

urinalysis

the microscopic and chemical analysis of urine to detect abnormalities characteristic of certain diseases

endoscopy

visual inspection of the body by means of an endoscope

colonoscopy

a diagnostic procedure in which a camera is inserted into the large intestine to examine the patient for signs of disease

lumbar puncture

a diagnostic procedure in which fluid is collected from the spinal canal to diagnose diseases affecting the central nervous system

barium swallow

a fluoroscopic diagnostic procedure to evaluate the function of the upper gastrointestinal tract

radiograph

a diagnostic image, or X-ray, created by applying radioactive X-rays to a portion of the body

ultrasound

a diagnostic technique that uses sound waves to create images of internal body structures

ech(o)

sound

electr(o)

electricity

fluor/o

emitting or reflecting light

-meter

instrument used to measure

-radi(o)

radiant energy

-scope

instrument used for viewing

-scopy

a visual examination

-gram

a record or recording

-graph

instrument used to record

-graphy

the process of recording

provider

a professional person, group, or organization that delivers healthcare services to a patient population

patient

an individual who requires medical attention

intake

the process by which patients enter the care of a medical facility

inpatient

a medical designation that indicates that a patient is receiving care after having been formally admitted to a healthcare provider

outpatient

a medical designation that indicates a patient is receiving care without having been formally admitted to a healthcare provider

discharge

when patients are cleared to leave the care of a medical facility and receive instructions for ongoing care and treatment

healthcare delivery

the process of getting health services to patients who need medical attention

healthcare system

an organized network that delivers medical care services

access to care

an individual’s ability to receive medical care based on factors like availability, location, cost, and ability to pay

insurance

a service that contracts with individuals and groups to provide medical services in exchange for regular payments from the individual through a provider

coverage

the specific group of healthcare services that an insurance provider is willing to reimburse healthcare providers for on behalf of their clients

premium

the required regular payment that an individual agrees to pay to an insurance company in exchange for insurance coverage

health savings account (HSA)

a tax-free savings account offered to individuals who are covered by insurance plans with high deductibles

health management organization (HMO)

a type of health insurance in which a group of healthcare providers accept insurance payments to provide specific health services to members of the plan at a renegotiated rate

preferred provider organization (PPO)

a type of health insurance in which a group of healthcare providers accept reduced rates for services from the insurance providers on behalf of the plan members

deductible

an amount of money that must be paid out by a member of an insurance plan before the insurance company will offer reimbursement

private insurance

an insurance plan in which patients pay monthly premiums for healthcare coverage, and submit claims for reimbursement

personal insurance plan

a health insurance plan in which a person sets aside money to use in the future to cover predicted medical expenses

nternational agencies

regulatory agencies that create regulations and recommendations and coordinate health services for a variety of communities worldwide

regulatory agency

an agency that writes the regulations intended to enforce a law

domestic agencies

agencies that write rules and coordinate services within the United States

Food and Drug Administration (FDA)

a domestic agency responsible for enforcing regulations of accurate labeling and safe handling of food and drugs

Occupational Safety and Health Administration (OSHA)

a domestic agency responsible for collecting data on workplace accidents and using that data to create regulations and recommendations

Joint Commission

a nonprofit organization that offers accreditation and certification to hospitals and healthcare centers in the United States

US Department of Health and Human Services

a federal regulatory agency that administers and manages many health organizations, systems, and programs

National Institutes of Health (NIH)

a domestic agency under the US Department of Health and Human Services that leads a number of medical research programs

Centers for Disease Control and Prevention (CDC)

a group of government agencies under the US Department of Health and Human Services that work to prevent the transmission of diseases and ensure the general protection of public health

National Institute for Occupational Safety and Health (NIOSH)

a domestic agency under the Centers for Disease Control and Prevention whose roles include researching the causes of workplace-related injuries and helping to prevent them

Medicare

a federal health insurance plan offered to those who are 65 years of age or older and some people with disabilities

Medicaid

a federal and state program that provides healthcare coverage for people with disabilities or lower incomes

World Health Organization (WHO)

an international agency that works to ensure that health care is available to people worldwide

Centers for Medicare and Medicaid Services (CMS)

a federal agency responsible for administering benefits in Medicare, Medicaid, and several other health insurance programs

AD

AD stands for Alzheimer’s disease, a degenerative disease that affects the functions of the brain and nervous system, leading to memory loss, forgetfulness, and irrational behavior.

ADD and ADHD

ADD and ADHD stand for attention deficit disorder and attention deficit hyperactivity disorder, respectively, a class of disorders that affect a person’s ability to concentrate on specific tasks.

AIDS

AIDS stands for acquired immunodeficiency syndrome, a disease in which the body is unable to fight to stay healthy.

AMI

AMI stands for acute myocardial infarction, which is formal medical terminology to describe a heart attack, a type of heart failure.

BA

BA stands for bronchial asthma, a condition in which the lungs become irritated, making it hard for an individual to breathe.

CA

CA stands for cancer, a condition that describes the uncontrolled growth of cells in the body.

CAD or CHD

CAD or CHD stands for coronary artery/heart disease, a condition caused by the obstruction of blood flow in the body.

CF

CF stands for cystic fibrosis, an inheritable disease that causes a build-up of mucus in the body, leading to organ damage.

CHF

CHF stands for congestive heart failure, a condition in which the heart can no longer sufficiently pump blood throughout the body and oxygen-rich blood can no longer be supplied to the heart.

COPD

COPD stands for chronic obstructive pulmonary disease, a chronic condition that results in difficulty breathing because the passages in the lungs that transfer air become clogged and misshapen.

DM

DM stands for diabetes mellitus, a disease in which the body has difficulty managing and regulating levels of sugar in the bloodstream.

FAS

FAS stands for fetal alcohol syndrome, a group of mental or physical defects that can develop in an unborn baby from the mother’s alcohol consumption during pregnancy.

FBOA

FBOA stands for foreign-body obstructed airway, an airway that has been obstructed by a foreign object, usually because the object has been swallowed.

FUO

FUO stands for fever of unknown origin, a diagnosis noted when a patient has a temperature of 101ºF or more several times over the course of three weeks and doctors cannot determine the cause.

Fx

Fx stands for fracture, a specific way that a bone has been broken.

HIV

HIV stands for human immunodeficiency virus, the harmful agent that causes people to get AIDS.

HPV

HPV stands for human papillomavirus, the virus that can cause warts, which are growths on the skin.

IBD

IBD stands for inflammatory bowel disease, a group of inflammatory conditions in the intestines.

IBS

IBS stands for irritable bowel syndrome, a disorder of the digestive system characterized by chronic bloating, discomfort, abdominal pain, and altered bowel habits.

LD

LD stands for learning disability, any number of diagnosable disabilities that affect a person’s ability to learn specific skills, such as reading, writing, speaking, or math.

MD

MD stands for muscular dystrophy, a group of muscle diseases that weaken and interfere with movement.

MS

MS stands for multiple sclerosis, a condition in which the body cannot properly send electrical messages to various parts, thereby limiting functionality.

OA

OA stands for osteoarthritis, a disorder that results in the degeneration of joints, which are the locations where bones connect in the body.

OCD

OCD stands for obsessive-compulsive disorder, a mental health disorder characterized by obsessive behaviors meant to ease anxieties.

PD

PD stands for Parkinson’s disease, a degenerative condition of the central nervous system that causes a loss of muscle control.

PE

PE stands for pulmonary embolism, the blockage of one of the main parts of the lungs, which are the parts of the body that support breathing.

SIDS

SIDS stands for sudden infant death syndrome, the sudden death of an infant that has no known medical history or cause.

STI

STI stands for sexually transmitted infection, any number of diseases that are transmitted through human sexual behaviors.

TB

TB stands for tuberculosis, an infectious and sometimes fatal disease that affects the lungs.

URI

URI stands for upper respiratory tract infection, an infection in the upper part of the respiratory system, which is the system in the body that supports breathing.

UTI

UTI stands for urinary tract infection, an infection in any part of the urinary system, which is the system of the body that collects and excretes liquid waste.

medical orders

Medical orders are instructions to medical staff.

no added salt (NAS)

No added salt indicates that a patient should not be given additional salt at meals.

no known allergies (NKA)

No known allergies describes a patient who has no recorded or known allergies.

nothing by mouth (NPO)

Nothing by mouth is a medical order instructing medical staff to not allow the patient to ingest any substances orally.

out of bed (OOB)

Out of bed indicates that a patient should get out of bed for a particular activity, or just for the exercise of getting out of bed.

bed rest (BR)

Bed rest is an order requiring consistent rest time in bed.

complete bed rest (CBR)

Complete bed rest is an order requiring that a patient remain in bed at all times.

bathroom privileges (BRP)

Bathroom privileges indicate that a patient has permission to use bathroom facilities unsupervised and at his or her own discretion.

do not resuscitate (DNR)

Do not resuscitate is a signed legal order that states that a patient is not to be administered life-saving procedures if the heart or breathing stops.

emergency procedures

Emergency procedures are actions performed in a hospital or at the scene of an emergency when someone requires immediate medical care.

medical procedures

Medical procedures are actions performed on a patient, which can include tests using sophisticated medical technology.

cardiopulmonary resuscitation (CPR)

Cardiopulmonary resuscitation is an emergency procedure administered to a patient whose heart has stopped beating.

magnetic resonance imaging (MRI)

Magnetic resonance imaging is an imaging technique that uses magnets to obtain structural or functional images of the body.

computer axial tomography (CAT)

Computer axial tomography is an imaging technique that uses invisible energy waves to obtain cross-sectional images of the body.

positron emission tomography (PET)

Positron emission tomography is an imaging technique that produces a three-dimensional image of a functional process in the body.

ultrasound (US)

Ultrasound is an imaging technique that uses sound waves to create images of structures inside the body.

electrocardiogram (ECG/EKG)

Electrocardiogram is a measurement of the electrical activity of the heart over a period of time.

electroencephalogram (EEG)

Electroencephalogram is a measurement of the brain’s spontaneous electrical activity over a period of time.

advanced cardiac life support (ACLS)

Advanced cardiac life support is a series of life-sustaining procedures administered in response to major heart traumas.

advanced life support (ALS)

Advanced life support is a series of procedures administered to a patient to sustain vital life processes, such as breathing and heartbeat.

alert, awake, and oriented (AAO)

Alert, awake, and oriented patients are awake, know who and where they are, recognize those around them, and know the date and time.

afebrile (afeb)

Afebrile indicates no fever and denotes a patient with a normal body temperature of approximately 98.6°F.

while awake (WA)

While awake indicates that an action must take place while the patient is awake.

loss of consciousness (LOC)

Loss of consciousness indicates that the patient at some point lost awareness and could not respond to cues.

range of motion (ROM)

Range of motion is a description of the ability of a patient to move his or her joints.

prescription (Rx)

Prescription indicates the drugs a patient is currently taking or has formerly been ordered to take.

prognosis (Px)

Prognosis is an indication of the probable course or outcome of a patient’s disease or condition.

blood pressure (B/P)

Blood pressure describes the pressure of the blood against the tubes that it travels through.

blood sugar (BS)

Blood sugar refers to the amount of glucose in a patient’s blood.

fasting blood work (FBW)

Fasting blood work is blood work taken after several hours of fasting, or not eating.

heart rate (HR or BPM)

Heart rate is a measure of how many times the heart beats in a minute.

keep vein open (KVO)

Keep vein open indicates that a catheter inserted into a blood vein should be kept at a constant drip rate.

Treatment (Tx)

Treatment is the current method of treating the patient’s symptoms.

History (Hx)

History refers to a patient’s medical history.

chief complaint (CC)

Chief complaint indicates the reason the patient is seeking medical attention.

discharge against medical advice (DAMA)

Discharge against medical advice is used on a discharge order to indicate that the patient requested to leave a medical facility although the medical supervisor advised against it.

stat

Stat means immediately, indicating that an order should be executed with no delay.

as needed (PRN)

As needed indicates that a medication should be dispensed as needed by the patient.

as tolerated (as tol)

As tolerated indicates that an activity can be done as long as it does not cause the patient discomfort.

b.i.d.

The abbreviation b.i.d. means twice a day, indicating that a prescription should be taken twice a day.

t.i.d.

The abbreviation t.i.d. means three times a day, indicating that a prescription should be taken three times a day.

ad lib

Ad lib means as desired, indicating that something is not restricted and may be done as the patient wishes.

Treatment (Tx)

Treatment is the current method of treating the patient’s symptoms.

History (Hx)

History refers to a patient’s medical history.

chief complaint (CC)

Chief complaint indicates the reason the patient is seeking medical attention.

discharge against medical advice (DAMA)

Discharge against medical advice is used on a discharge order to indicate that the patient requested to leave a medical facility although the medical supervisor advised against it.

stat

Stat means immediately, indicating that an order should be executed with no delay.

as needed (PRN)

As needed indicates that a medication should be dispensed as needed by the patient.

as tolerated (as tol)

As tolerated indicates that an activity can be done as long as it does not cause the patient discomfort.

b.i.d.

The abbreviation b.i.d. means twice a day, indicating that a prescription should be taken twice a day.

t.i.d.

The abbreviation t.i.d. means three times a day, indicating that a prescription should be taken three times a day.

ad lib

Ad lib means as desired, indicating that something is not restricted and may be done as the patient wishes.

Doctor of Medicine (MD)

a title that is granted upon completion of a rigorous course of study in an accredited medical school, enabling the titleholder to examine patients, recommend a course of treatment, and prescribe medication

Doctor of Osteopathic Medicine (DO)

a title that is equivalent to an MD, but focuses more on holistic and alternative solutions to medical issues

obstetrician (OB/GYN)

a physician who specializes in monitoring the health of mothers and babies during pregnancy, labor, and childbirth

physical therapist (PT)

a medical professional who attempts to reduce dysfunction in the musculoskeletal system by improving joint mobility, muscle strength, balance, and coordination; also called a physiotherapist

Doctor of Medicine (MD)

a title that is granted upon completion of a rigorous course of study in an accredited medical school, enabling the titleholder to examine patients, recommend a course of treatment, and prescribe medication

Doctor of Osteopathic Medicine (DO)

a title that is equivalent to an MD, but focuses more on holistic and alternative solutions to medical issues

obstetrician (OB/GYN)

a physician who specializes in monitoring the health of mothers and babies during pregnancy, labor, and childbirth

physical therapist (PT)

a medical professional who attempts to reduce dysfunction in the musculoskeletal system by improving joint mobility, muscle strength, balance, and coordination; also called a physiotherapist