Download comprihending x-rays, mri`s, ct scans and other

MEDICAL TERMINOLOGY AND
DOCUMENTATION PRIMER
By:
Jennifer Gallaway
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS

Deciphering Medical Terminology
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Deciphering medical terminology can be a very
daunting and difficult task.
Medical terminology is based in both Greek and
Latin languages.
Medical terms are made up of three main parts;
word roots, prefixes, and suffixes.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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The word root is derived from a source language such as
Greek or Latin and usually describes a body part. The word
root tells the subject of the medical term.
A prefix or suffix is added to the word root to expand and
describe in more detail.
The prefix may be added to the front of a word root and will
give additional information about the location of an organ,
the number of parts, or time involved.
The suffix may be added to the end of a word root to add
meaning such as condition, disease process, or procedure.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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If the word root is in the Greek language, a Greek
prefix or suffix would be used. If the word root is
in the Latin language, a Latin prefix or suffix
would be used.
In addition to the three main parts of a medical
term, a vowel is used to join two word roots or
between the prefix and the word root. The letter
-o is most commonly used to join two word roots.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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The combinations to build a medical term are
almost endless, so we will go over a few
examples that might be useful to an attorney.
Common medical terms found in the chart of a
client presenting with a back injury might be
discogram, discectomy, and laminectomy.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Discogram
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Discectomy
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Disc(o) is a word root referring to an intervertebral disc.
-gram is the suffix meaning a record or picture.
When put together, the term discogram means a record or picture of an
intervertebral disc.
Disc(o) is a word root referring to an intervertebral disc.
-ectomy is the suffix denoting a surgical operation or removal of a body part.
When put together, the term discectomy means the surgical operation or removal
of an intervertebral disc.
Laminectomy
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Lamina is a word root referring to the lamina of the spine.
-ectomy is the suffix denoting a surgical operation or removal of a body part.
When put together, the term laminectomy means the surgical operation or
removal of the lamina of the spine.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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When a client presents with pain or numbness in
the hand or wrist, a medical term that might be
found in the chart is metacarpal.
Metacarpal
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Meta- is a prefix meaning after or behind.
Carpal(carpus) is the word root meaning sole cluster of
bones in the wrist.
When the two are put together, the term metacarpal
means after or behind the sole cluster of bones in the
wrist.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Two word roots can be combined to form a medical term as
well.
Another common medical term is cerebrospinal. When
splitting the term cerebrospinal we find two word roots
joined by the letter -o.
Cerebrospinal
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Cerebr(o) means of or pertaining to the brain.
Spinal means the spine or spinal cord.
When the two are put together, the term cerebrospinal means
of or pertaining to the brain and spine or spinal cord.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Deciphering Medical Acronyms or
Abbreviations
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Deciphering medical acronyms or abbreviations
can be just as difficult as deciphering medical
terminology.
Medical acronyms might have a Greek or Latin
base.
Some of the most common medical acronyms are
in regard to time and the directions for taking
medications.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Medication prescription: “Take 1 tab po qid pc and hs”
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“Take 1 tablet by mouth 4 times a day, after meals and at
bedtime.”
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po(per os) means by mouth.
– qid(quater in die) means 4 times a day.
– pc(post cibum) means after meals.
– hs(hora somni) means at bedtime.
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Other common acronyms are:
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Bid(bis in die)- twice a day
Tid(ter in die)- three times a day
Prn(pro re nata)- as needed
C(cum)- with
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Other medical acronyms or abbreviations
commonly found in the medical record pertain to
activities, a place in the body or in the hospital, a
type of test, a person's credentials, etc. These
abbreviations are usually an abbreviation of a
term in the English language.
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Common abbreviations:
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BP(blood pressure)
CV(cardiovascular)
c/o(complain of)
CC(chief complaint)
CXR(chest x-ray)
CTS(carpal tunnel
syndrome)
DJD(degenerative joint
disease)
Dx(diagnosis)
ETOH(alcohol)
HA(head ache)
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HR(heart rate)
Hx(history)
IDDM(insulin dependent
diabetes mellitus)
LBP(low back pain)
LOC(level of
consciousness)
MVC(motor vehicle crash)
MD(medical doctor)
PA(physician's assistant)
RN(registered nurse)
MA(medical assistant)
DECIPHERING COMMON MEDICIAL
TERMINOLOGY AND ACRONYMS
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Many medical personnel find it faster and easier
to document using abbreviations and acronyms
for medical terminology.
This practice is acceptable in medical
documentation.
Pay attention to the context surrounding the
medical term or acronyms in a medical record.
The documentation itself can assist in deciphering
medical terminology or acronyms.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Medical Records and
Hospital Charts Give a
Description of the Client.
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Valuable information about the
client can be found in the chart
that can determine the
outcome of a case.
Client's age
Past and present medical
history
Current medical treatment and
his/her compliance with the
suggested medical treatment
Degree and extent of his/her
injury
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Subsequent accidents, injuries
and claims
Lifestyle and habits
Occupational history
Comparative and contributory
negligence
Lab results, radiology reports,
cardiology reports, and consult
information
Client's short and long term
prognosis as well as future
healthcare needs and costs
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Details of the client's age, injury, and past and
present medical history can be easily found in
multiple areas of a medical record.
The admission record is a good place to find
information such as the client's age, diagnosis,
time of admission, etc.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Emergency room/trauma record
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Fastest and easiest places to find a brief overview.
Details of the injury the client sustained.
The details are usually in the client's own words and are
documented closest to the time of injury, typically
making them more accurate.
Client's alcohol and drug test results.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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History and physical
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More detailed explanation of the client's history.
Client's preexisting conditions.
If a client sustains a spinal cord injury, his/her preexisting
conditions may have an influence on the case outcome.
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osteoarthritis or rheumatoid arthritis
 Spine may be weakened
– degenerative disc disease
 Difficult to prove
– Diabetes
 Effects the healing process
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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History and physical
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With an obese client who sustains a knee injury, the
client's obesity may make the case more complex and
can have an effect on the outcome of a case.
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Difficult to prove
Age can also have an effect on the outcome of a case.
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The normal aging process can make bones, joints, and
tissue more susceptible to injury.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Details of a client's lifestyle, habits, smoking
history, etc. can also be found in multiple
locations within a medical record.
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Admission record
ER record
History and Physical
Progress notes
Nurse's notes
Doctor's office notes
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Smoking history
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If a client who sustains a spine injury has a history of
smoking, a treating physician may document that
information in his/her notes because smoking has a
direct effect on the healing process of spine.
It is important to look for evidence of smoking
throughout the medical record because of smoking's
negative impact on bone healing as well.
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The client may not list a history of smoking in the
admission orders or health history, but a nurse may
document in the nurse's notes if the client is found leaving
the unit to smoke.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Client’s lifestyle and habits
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Can be found in the history and physical, nurse's notes,
doctor's office notes.
If a client regularly engages in risky activities, that
information could be taken into consideration when
assessing injury.
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The risky behavior could mean additional wear and tear
on the client's body, possibly making him/her more
susceptible to injury.
– It could also mean an additional injury after the initial
claimed injury.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Client's occupational history
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Can be found in the admission record, history and
physical, doctor's office notes, and possibly the ER
record.
If the client's occupation is one that is physically
demanding or might increase the normal wear and tear
on a person's body
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It could make him/her more susceptible to injury.
– It could also mean an additional injury after the initial
claimed injury.
– The client may have to stop working after the injury if
his/her job is too physically demanding.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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The client's current medical treatment and
whether the client is compliant to suggested
medical treatment.
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The details are usually found in the treating physician's
office record, and possibly the physician's notes in the
hospital record.
If a client has not been compliant to his/her suggested
medical treatment
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it might shed a negative light on the client as well as the
case.
– it could mean that he/she will not follow through with
suggested medical treatment in the future.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Other Details Found in a Medical Record or
Hospital Chart.
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Lab results, radiology reports, cardiology reports, and
consult information can be found throughout the medical
record in their respective sections.
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Lab results can show a multitude of details from preexisting
medical conditions to alcohol and drug levels.
Radiology reports can show the actual injury the client might
have sustained and give the details of the injury.
Consult information can be valuable when trying to follow the
course of care of a client and can also outline the suggested
medical treatment.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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The billing statement
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The billing statement can be helpful when trying to
determine recovery and damages.
The billing statement outlines the details of the medical
bills accrued during the course of treatment of the client
as well as assists with determining the client's projected
future medical expenses.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Surgery records and procedure records
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It might be important to know the procedures, if any, the
client has had for the treatment or investigation of their
injury as well as the outcomes of those tests and
treatments.
The results of the procedures the client might have
underwent may help diagnose his/her medical problem
and assist in producing the overall picture of the client.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Evidence of tampering with a medical record
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Missing documents are one sign of tampering.
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If a test is ordered in the doctor's orders or is charged for in the
billing statement but the results are not in the chart, this might be
an alert signal.
Information that has been added, crossed out, or changed in
any way, this might be an alert signal.
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If a document is copied and sent to another treating physician or
facility, it is important to compare the original and the copies.
– There is an acceptable timeframe that a hospital chart is allowed
to be corrected after the initial charting.
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Nurses commonly end their note by drawing a line through the
rest of the charting space to their name. Check those details.
Tampering of a medical record is very difficult if not impossible
to defend because the entire document loses credibility.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Electronic medical records
Are being utilized more and more in many hospitals and
healthcare facilities.
Each documentation entered on the chart is recorded in a
tracing log, leaving a trail of who entered what.
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Often times the detailed tracing log is only available to be
viewed at the facility using that facility's specific program and
does not necessarily show up on the printed version.
If tampering of the EMR is suspected, viewing the entire
tracing log may be useful.
WHAT MEDICAL RECORDS AND
HOSPITAL CHARTS CAN TELL YOU
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Summary
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Medical records and hospital charts can give a detailed
description of the client that can determine the outcome of a
case.
All of the procedures, lab and radiology reports, and
medical expenses, as well as the healthcare providers
involved in the client's care can be found in the medical
record and hospital chart.
It is important to examine an entire medical record and
hospital chart to form an educated opinion of a case.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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X-rays
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The basic radiological exam used in diagnostic
imaging and usually the first diagnostic test for
examining bones.
A form of electromagnetic radiation that produces
a 2 dimensional image.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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X-rays
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How x-rays work.
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The part of the patient to be x-rayed is placed between
the x-ray source and the image receptor and produces a
shadow of the internal image.
Higher density tissue essentially blocks the x-rays from
reaching the image receptor. Bones, having a higher
density, absorb more radiation than soft tissue and show
up more detailed on film.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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X-rays
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Uses
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Useful for the detection of pathology of the skeletal
system, but are also useful for the detection of some
disease processes in soft tissue.
Used to identify lung diseases by showing masses or
fluid.
Used to identify abdominal problems by showing bowel
obstruction, free air, and free fluid in the abdomen.
Used in detecting gallstones and kidney stones as well
as foreign bodies.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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Contrast dye is used in radiological exams.
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Contrast helps to show the structure of vessels, ducts,
and hollow organs of the body.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS

X-rays
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Flouroscopy
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A form of 2 dimensional x-ray where contrast is often
utilized for the exam of internal body structures.
Used in real time exams such as angiograms and
cholangiograms where contrast is injected into a vessel
or duct and continuous imaging is utilized to examine
the contrast as it travels through the tissue being
examined.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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Ultrasounds
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A diagnostic medical imaging technique used to
visualize muscles, tendons, and many internal
organs.
Real time exam.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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Ultrasounds
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Uses
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Used to guide interventional procedures such as a fine
needle aspiration or a biopsy of a mass for cytology or
histology testing.
Used to visualize arteries, veins, and nerves.
Use in sonography to produce pictures of a fetus in a
mother's womb.
Increasingly being used in trauma and first aid cases
because of the instantaneous results seen.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE
TEST RESULTS
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CT scans
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The next step in radiological exams and are used
to supplement x-rays and ultrasound.
Generate a 3 dimensional image of the object
being examined.
Uses an x-ray beam, so it depends on the tissue's
ability to block an x-ray beam, making it best
suited to examine dense tissue like bone.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS

CT scans
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How CT scans work.
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Provide a picture of a thin slice of tissue.
These thin slices are placed together to provide the
overall image that can be viewed in multiple planes.
Eliminate the superimposition or layering of structures in
the image, making the image more clear.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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CT scans
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Uses
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Can be used for all of the basic x-rays tests, but with
more clarity and detail.
Used to examine the brain, which a basic x-ray would be
unable to do.
Used to examine extremities for complex fractures
especially near joints where basic x-rays would not be
adequate.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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CT scans
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Uses
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Used to show greater detail of vertebra as well as the
spacing between vertebra in spinal exams.
Used in abdominal exams to find cysts, abscesses,
infection, tumors, foreign bodies, bleeding, appendicitis
and much more.
Used in the chest to look for problems in the lungs,
heart, vessels, etc.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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CT scans
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Can be done very quickly, making it ideal for a
more comprehensive radiological exam in
emergency and trauma situations.
A patient would not need to be still for as long as
he/she would for an MRI.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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MRIs
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Use a magnetic field and pulses of radio wave energy to
make pictures or organs and structures of the body.
Provide a 3 dimensional image of the object being
examined.
Unlike basic x-rays and CT scans, MRIs do not use
radiation.
Provide a good contrast between different hard and soft
tissues of the body and are especially useful in imaging the
brain, muscles, the heart, and cancers.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS

MRIs
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Uses
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Used to examine the disc and nerves of the spine for
conditions such as bulging discs, spinal stenosis, and
spinal tumors.
Useful in examining joints for multiple problems
including broken bones, cartilage problems, tumors, and
ligament and tendon tears.
Assist in the examination of the pelvic region where the
use of x-rays and CT scans are limited.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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MRIs
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Not everyone is a candidate for MRIs due to the
strong magnets used.
MRIs are generally more expensive and less
available than CT scans and take longer to
complete, which means MRIs are not typically the
first radiological exam completed.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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Common Content in a Radiology Report
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Radiology reports are usually similar in their
content.
A radiology report may tell the type of test run like
X-ray, ultrasound, CT, MRI, angiogram, or
cholangiogram.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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Radiology reports
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May tell the reason for the test and might tell the location
of pain, numbness, or problem.
Might also give insight to what the doctor(s) might be
looking for.
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This information may give useful insight to an attorney.
May tell the technique used.
May tell if contrast was used and how the test was
completed.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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Radiology reports
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May tell the findings of the test.
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Might tell of any problems and where the problems are
located along with any normal findings.
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This section will give the test results and describe what
and how tissues were examined.
This section is useful in determining the extent of injury, if
there is any.
Will probably give the radiologist's impression of the
exam, summarizing the findings and results, possibly
giving an explanation of the results.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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Other Diagnostic Tests
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Lab results
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Can provide a picture of the client's health status as well
as show alcohol and drug levels.
Usually contains a heading describing the test run.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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Common headings in lab
results
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Hematology (description of
blood cells)
Chemistry (description of
certain chemical
components found in the
blood stream or tissues)
Urinalysis (description of
urine and urinary
sediments and
components)
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Bacteriology/Microbiology
(description of bacteria
that may be found in the
body)
Immunology (description of
the body's defense
substances, called
antibodies)
Endocrinology (description
of hormones)
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS
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Lab results
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Usually in column format.
Usually a column for the name of the item tested, a
column for that tested item's result, a column for that
tested item's result flag, and a column for the normal
range for that tested item.
Usually a legend that explains what certain letters (flags)
stand for. Such flag letters might be H(high), L(low),
CH(critical high), CL(critical low). No flag letter usually
means a normal result.
COMPRIHENDING X-RAYS, MRI'S, CT
SCANS AND OTHER DIAGNOSTICE TEST
RESULTS

Summary
– Comprehending x-rays, MRIs, CT scans and
other diagnostic test results can be overwhelming.
But with the basic understanding of the uses,
differences, and similarities of diagnostic tests,
the results can comprehend more efficiently.
– Medical records can be bulky and cumbersome.
But with the knowledge of efficient ways to find
useful information and decipher medical terms,
medical record reviews can be easy.