Medical Terminology & Documentation Flashcards
9 cards from real CPMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 9 Medical Terminology & Documentation flashcards as text
What is the primary purpose of medical terminology in documentation?
Answer: To standardize communication and improve clarity
Medical terminology provides a universal language for healthcare professionals, ensuring precise and unambiguous communication. It standardizes the description of conditions, procedures, and anatomy, which is crucial for patient safety and effective care. This clarity minimizes misunderstandings among providers, leading to more accurate diagnoses and treatment plans.
What does the abbreviation 'PRN' stand for in medical documentation?
Answer: As needed
In medical documentation, 'PRN' is a Latin abbreviation for "pro re nata," which translates to "as needed." This instruction indicates that a medication or treatment should be administered only when a specific symptom or condition arises, rather than on a fixed schedule. It gives healthcare providers flexibility in patient care based on their current needs.
Which of the following is an example of a medical diagnosis?
Answer: Asthma
A medical diagnosis is the identification of the nature of an illness or other problem by examination of the symptoms. While coughing, temperature fluctuation, and fatigue are symptoms, asthma is a specific, recognized chronic respiratory condition. It represents a definitive medical conclusion about a patient's health state, rather than just an observable sign.
What is the meaning of the medical term 'hypertension'?
Answer: Elevated blood pressure
The medical term 'hypertension' literally means "high tension" and refers to a condition where the blood pressure in the arteries is persistently elevated. This sustained high pressure can lead to serious health problems like heart disease and stroke if left untreated. It is a critical indicator of cardiovascular health that healthcare professionals monitor closely.
What is the purpose of the ICD-10 coding system?
Answer: To classify diseases and procedures
The ICD-10 (International Classification of Diseases, 10th Revision) is a globally recognized system used by healthcare providers to classify and code all diagnoses, symptoms, and procedures. Its primary purpose is to standardize the recording of health information, facilitating accurate data collection for epidemiological studies, billing, and public health initiatives. This system ensures consistent communication and data analysis across different healthcare settings.
What does the medical abbreviation 'BID' stand for?
Answer: Twice a day
In medical documentation, 'BID' is a common Latin abbreviation that stands for "bis in die," meaning "twice a day." This instruction is frequently used in medication orders to specify the frequency at which a drug should be administered. It ensures clarity and consistency in patient treatment plans.
What is the correct order of components in a medical history documentation?
Answer: Personal information, chief complaint, medical history, medications, family history
A structured approach to medical history documentation ensures all critical information is systematically collected and easily retrievable. The typical order begins with personal information for patient identification, followed by the chief complaint to understand the immediate reason for the visit. This is then expanded upon with the patient's past medical history, current medications, and relevant family history to provide a comprehensive health profile.
What is the medical abbreviation for 'with'?
Answer: C
In medical documentation, the letter 'C' with a line over it (often represented as 'c' or 'C' in text) is the standard abbreviation for "with." This abbreviation originates from the Latin word "cum," meaning "with." It is commonly used to concisely indicate that a symptom, condition, or treatment is associated with something else, such as "pain c nausea."
What does 'HPI' stand for in medical documentation?
Answer: History of Present Illness
In medical documentation, 'HPI' stands for History of Present Illness. This section provides a detailed chronological description of the patient's chief complaint, including its onset, duration, location, character, aggravating/alleviating factors, and associated symptoms. The HPI is crucial for understanding the patient's current condition and guiding the diagnostic and treatment process.