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MEDICAL TERMINOLOGY AND DOCUMENTATION PRIMER By: Jennifer Gallaway DECIPHERING COMMON MEDICIAL TERMINOLOGY AND ACRONYMS Deciphering Medical Terminology – – – 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 – – – – 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 – – 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 – – 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 – Discogram – Discectomy – 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 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 – – 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 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 – – – 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 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 Deciphering Medical Acronyms or Abbreviations – – – 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 – Medication prescription: “Take 1 tab po qid pc and hs” “Take 1 tablet by mouth 4 times a day, after meals and at bedtime.” – 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. – Other common acronyms are: 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 – 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 – Common abbreviations: 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) 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 – – – 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 Medical Records and Hospital Charts Give a Description of the Client. – – – – – 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 – – – – – – 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 – – 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 – Emergency room/trauma record 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 – History and physical 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. – 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 – History and physical 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. – Difficult to prove Age can also have an effect on the outcome of a case. – The normal aging process can make bones, joints, and tissue more susceptible to injury. WHAT MEDICAL RECORDS AND HOSPITAL CHARTS CAN TELL YOU – Details of a client's lifestyle, habits, smoking history, etc. can also be found in multiple locations within a medical record. 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 – Smoking history 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. – 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 – Client’s lifestyle and habits 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. – 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 – Client's occupational history 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 – 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 – The client's current medical treatment and whether the client is compliant to suggested medical treatment. 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 – 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 Other Details Found in a Medical Record or Hospital Chart. – Lab results, radiology reports, cardiology reports, and consult information can be found throughout the medical record in their respective sections. 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 – The billing statement 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 – Surgery records and procedure records 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 – Evidence of tampering with a medical record Missing documents are one sign of tampering. – 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. – 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. 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 – – – 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. 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 Summary – – – 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 X-rays – – 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 X-rays – How x-rays work. 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 X-rays – Uses 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 – Contrast dye is used in radiological exams. 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 – Flouroscopy 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 Ultrasounds – – 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 Ultrasounds – Uses 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 CT scans – – – 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 – How CT scans work. 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 CT scans – Uses 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 CT scans – Uses 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 CT scans – – 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 MRIs – – – – 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 – Uses 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 MRIs – – 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 Common Content in a Radiology Report – – 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 – Radiology reports 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. – 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 – Radiology reports May tell the findings of the test. – Might tell of any problems and where the problems are located along with any normal findings. – 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 Other Diagnostic Tests – Lab results 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 – Common headings in lab results 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) 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 – Lab results 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.