INTRODUCTION TO MEDICAL TERMINOLOGY- glossary

acute care hospital (general hospital)

Hospitals that typically provide services to diagnose (laboratory, diagnostic imaging) and treat (surgery, medications, therapy) diseases for a short period of time. In addition, they usually provide emergency and obstetrical care.

ambulatory care center (ambulatory care or a surgical center)

A facility that provides services that do not require overnight hospitalization. The services range from simple surgeries, to diagnostic testing, to therapy. Also called a surgical center or an outpatient clinic.

ancillary reports

Reports in a patient's medical record from various treatments and therapies the patient has received, such as rehabilitation, social services, respiratory therapy, or from the dietician.

anesthesiologist's report

A medical record document that relates the details regarding the drugs given to a patient and the patient's response to anesthesia and vital signs during surgery.

combining form

The word root plus the combining vowel. It is always written with a / between the word root and the combining vowel. For example, in the combining form cardi/o, cardi is the word root and /o is the combining vowel.

combining vowel

A vowel inserted between word parts that makes it possible to pronounce long medical terms. It is usually the vowel o.

consultation reports

Documents in a patient's medical record. They are the reports given by specialists who the physician has requested to evaluate the patient.

diagnostic reports

Found in a patient's medical record. It consists of the results of all diagnostic tests performed on the patient, principally from the lab and medical imaging (for example, X-ray and ultrasound).

discharge summary

Part of a patient's medical record. It is a comprehensive outline of the patient's entire hospital stay. It includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans

health maintenance organization (HMO)

An organization that contracts with a group of physicians and other health care workers to provide care exclusively for its members. It pays the health care workers a prepaid fixed amount per member whether that member requires medical attention or not.

history and physical

Medical record document written by the admitting physician. It details the patient's history, results of the physician's examination, initial diagnoses, and physician's plan of treatment.

home health care

Agencies that provide nursing, therapy, personal care, or housekeeping services in the patient's own home.

hospice

An organized group of health care workers that provide supportive treatment to dying patients and their families.

informed consent

A medical record document, voluntarily signed by the patient or a responsible party, that clearly describes the purpose, methods, procedures, benefits, and risks of a diagnostic or treatment procedure.

long-term care facility (nursing home)

A facility that provides long-term care for patients who need extra time to recover from an illness or accident before they return home or for persons who can no longer care for themselves.

medical record (chart) II

Documents the details of a patient’s hospital stay. Each health care professional that has contact with the patient in any capacity completes the appropriate report of that contact and adds it to the medical chart.

medical record (chart) II

This results in a permanent physical record of the patient’s day-to-day condition, when and what services he or she receives, and the response to treatment.

nurse's notes

Medical record document that records the patient's care throughout the day. It includes vital signs, treatment specifics, patient's response to treatment, and patient's condition.

operative report

A medical record report from the surgeon detailing an operation. It includes a pre- and postprocedure itself, and how the patient tolerated the procedure.

pathologist's report

A medical record report given by a pathologist who studies tissue removed from the patient (for example: bone marrow, blood, or tissue biopsy).

physician's offices

Individual or groups of physicians providing diagnostic and treatment services in a private office setting rather than a hospital.

physician's orders

Medical record document that contains a complete list of the care, medications, tests, and treatments the physician orders for the patient.

physician's progress notes

Part of a patient's medical record. It is the physician's daily record of the patient's condition, results of the physician's examinations, summary of test results, updated assessment and diagnoses, and further plans for the patient's care.

prefix

A word part added in front of the word root. It frequently gives information about the location of the organ, the number of parts or the time (frequency). Not all medical terms have a prefix.

rehabilitation centers

Facilities that provide intensive physical and occupational therapy. They include inpatient and outpatient treatment.

specialty care hospitals

Hospitals that provide care for very specific types of disease. A good example is a psychiatric hospital.

suffix

A word part attached to the end of a word. It frequently indicates a condition, disease, or procedure. Almost all medical terms have a suffix.

surgical center

A facility that provides services that range from simple surgeries to diagnostic testing to therapy and do not require overnight hospitalization. Also called an ambulatory care center or an outpatient clinic.

word root

The foundation of a medical term that provides the basic meaning of the word. In general, the word root will indicate the body system or part of the body that is being discussed. A word may have more than one word root.