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A comprehensive overview of essential medical terminology and healthcare concepts. It covers a wide range of topics, including empathy, patient status, healthcare regulations (hipaa, hitech), electronic health records (ehr), medical record charting styles (soap, pomr), insurance policies, and common medical prefixes, suffixes, and root words. Additionally, it includes information on musculoskeletal system terminology, fractures, and joint movements. Useful for students and professionals in healthcare fields, offering a structured approach to understanding key concepts and terminology. It serves as a valuable resource for exam preparation and quick reference, enhancing comprehension and application of medical knowledge. Well-organized and detailed, making it an excellent study aid for anyone seeking to improve their understanding of medical terminology and healthcare practices.
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Empathy ✔✔Having an understanding and compassion for what the patient may be experiencing Established Patient ✔✔Has been seen by the physician within 3 years New Patient ✔✔Hasn't been to the physician in 3 years CMS ✔✔Center for Medicare and Medicaid services HIPAA Title I ✔✔Healthcare Access, Portability and Renewability HIPAA Title II ✔✔Preventing Health Care Fraud and Abuse HIPAA Title III ✔✔Tax Related Health Provisions
HIPAA Title IV ✔✔Application and Enforcement of Group Health Plan Requirements HIPAA Title V ✔✔Revenue Offsets HIPAA ✔✔Health Insurance and Accountability Act Expressed Consent ✔✔A patient acknowledges that they have received proper direction regarding the nature of their medical treatment verbally or by signing a comment form Implied Consent ✔✔A patient uses body language top indicate that they agree to receive a form of medical care Respondeat Superior ✔✔"let the master answer"; physician is responsible for medical staff mistakes Coordination of Benefits ✔✔C.O.B; Indicates how a policy well pay when more than one insurance plan is in effect
Core Function of EHR ✔✔Reporting and population management Electronic Medical Records (EMR) ✔✔Computerized records of one physicians encounter with a patient over time (intranet) Electronic Health Records (EHR) ✔✔Reflects the data from ALL sources that have treated the individual (interoperable to other facilities) Acute Care ✔✔Most often refers to a hospital, treats patients with urgent problems that cannot be handled Personal Health Records (PHR) ✔✔Maintained and owned by the patient Ambulatory Care ✔✔Refers to treatment without admission to hospital Clinical Templates ✔✔Allows doctors to document patient encounters into an EHR on a structured form
RADT ✔✔Registration, admissions, discharge, transfer Unique Patient Identifier (UPI) ✔✔Links all clinical observations, tests, procedures, villains, evaluations, and diagnoses to the patient Clinical Vocabularies ✔✔Set a common definitions for medical terms that ease communication by decreasing uncertainty SNOMED-CT ✔✔Clinical vocabulary designed to encompass all trends used in medicine LOINC ✔✔Trends and codes used for electronic exchange of lab results and clinical observations UMLS ✔✔Thesaurus database of medical terms Fixed Appointment Scheduling ✔✔One patient is scheduled for a specific appointment time
Assessment ✔✔A brief summary of the patients symptoms, and may often include a diagnosis as well as a list of other possible diagnoses Plan ✔✔Consists of any information regarding the prescribed plan of action for a patient (prescriptions, instructions, referrals) Problem Oriented Medical Record (POMR) ✔✔Charting that tracks patients problems during the time they are receiving medical care Progress Notes ✔✔Daily chart notes which are used to record any information that Irish to the various stages of a patients condition Flow Chart ✔✔A visual aid used to keep track of information over a period of time Alphabetic Filing System ✔✔Information is filed according to the patients last name Numeric Filing System ✔✔Information regarding each patient is stored used a number, instead of the last name
A Medical Record Contains... ✔✔Personal information, financial information, medical information and social information Personal/Financial Information ✔✔Includes insurance data, marital status, next of kin, and other items collected for personal identification Medical Information ✔✔Includes the chief complaint, family/patient medical history, results of exams, physical exam form, lab reports, etc. Social Information ✔✔Includes items such as race, ethnicity, hobbies, lifestyle choices Self-Insure ✔✔A method in which the employer pays directly for the employees medical bills Medicare ✔✔Federal program for patients that are either over the age of 65, disabled, or considered end-stage renal disease patients Medicaid ✔✔Federal program, state administered, for individuals/families that have very low income
Participating Provider (Preferred) ✔✔Physicians who agree to accept the allowed amount from the insurance company as a payment in full Copayment ✔✔A fixed amount a patient may be required to pay at the time of their appointment Coinsurance ✔✔A set percentage of charges that the patient pays in surfing to the guidelines set forth by their policy (80/20) Deductible ✔✔A set amount the patient may be required to pay the provider before they can receive services Beneficiary ✔✔A patient covered by a federal program, such as Medicare or Medicaid Word Root ✔✔Foundation of a med term Suffix ✔✔Med term ending
Prefix ✔✔Med term beginning Combing Vowel ✔✔Links the root to the suffix or another root Combing Form ✔✔Word root plus the appropriate combining vowel Arthr/o ✔✔Joint Bi/o ✔✔Life Cardi/o ✔✔Heart Carcin/o ✔✔Cancerous, cancer Cephal/o ✔✔Head Cerebr/o ✔✔Cerebrum
Sarc/o ✔✔Flesh Thromb/o ✔✔Clotting Ur/o ✔✔Urinary tract
Limited ROM ✔✔Amphiathroses are joints joined together by cartilage that is slightly moveable, such as vertebrae of the spine or the pubic bone Full ROM ✔✔Diathroses are joints that have free movement. Ball-of-sockets (hip) and hinge joints (knees) are common diathroses joints, (synovial joints) Synovial Joints ✔✔Free moving joints, are surrounded by joint capsules. Bursae ✔✔Sacs of fluid that are located between the bones out the joint and the tensions that hold the muscle in place Extension ✔✔To increase the angle of the joint Flexion ✔✔To decrease the angle of the joint Abduction ✔✔Movement away from the midline Adduction ✔✔Movement towards the middle
Rotation ✔✔Revolving a bone around its axis Fracture ✔✔A broken bone Comminuted Fracture ✔✔The bone is crushed or shattered Compression Fracture ✔✔The fractured area of bone collapse on itself Colles Fracture ✔✔The break of the distal end of the radius at the epiphysis often occurs when the patient has steroid to break his or her fall Complicated Fracture ✔✔The bone is broken and pierces an internal organ Impacted Fracture ✔✔The bone is broken and the ends are driven into each other Hairline Fracture ✔✔A minor fracture spotters as a thin line on x-ray and may not extend completely through the bone
Greenstack Fracture ✔✔The bone is partially bent and partially broken; this is a common fracture in children because their bones are still soft Salter-Harris Fracture ✔✔A fracture of the epiphyseal plate in children Pathologic Fracture ✔✔A fracture occurring spontaneously as a result of disease Sprain ✔✔A traumatic injury to a joint involving soft tissue (muscles, ligaments, tendons) Strain ✔✔A result of overuse or overstretching Dislocation ✔✔When a bone comes completely out of place and subluxation is partially out of joint ICD- 10 Volume 1 ✔✔Tabular list ICD- 10 Volume 2 ✔✔Instruction module
