Medical Terminology and Documentation Flashcards
6 cards from real CPCT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Terminology and Documentation flashcards as text
The term 'proximal' in anatomical directional terminology means:
Answer: Closer to the point of origin or attachment
Proximal means closer to the point of attachment or origin; for example, the elbow is proximal to the wrist.
What does the medical abbreviation 'PRN' mean in a medication order?
Answer: As needed
PRN (pro re nata, Latin) means 'as needed,' indicating the medication should be given only when specific conditions are met.
Which of the following statements is an example of objective documentation?
Answer: Patient's blood pressure is 142/88 mmHg
Objective documentation records measurable, observable facts; a specific blood pressure number is objective, while 'appears' or 'seems' are subjective interpretations.
What does 'cc' mean as a measurement in clinical documentation?
Answer: Cubic centimeters, equivalent to milliliters (mL)
1 cc equals 1 mL and the two are used interchangeably in clinical fluid measurement.
The medical term 'hematuria' means:
Answer: Blood in the urine
Hematuria is derived from 'hemato-' (blood) and '-uria' (urine condition), meaning the presence of blood in the urine.
Regarding confidentiality, a PCT may share patient information with:
Answer: Members of the care team directly involved in the patient's care
HIPAA permits sharing patient information only with members of the treatment team on a need-to-know basis to provide care.