CMA

Medical terminology provides a standardized language for health care communication. Terms derive primarily from Greek and Latin roots, and understanding word construction lets you interpret unfamiliar terms. A term is built from a word root (core meaning), a combining vowel (usually "o," connecting roots to suffixes), a prefix (modifies the meaning at the beginning), and a suffix (modifies the meaning at the end). The combining form is the root plus the combining vowel.

MeaningGroup	Prefi xes
Number	mono- (one) , bi - (two) , tri - (three) , quadri - (four) , multi - (many) , poly- (many/excessive)
Size	micro- (small) macro- (large) mega- (enlarged) , ,
Location	epi - (above/upon) , hypo- (below/under) , sub - (under) , supra- (above) , infra- (below) , inter- (between) , intra-
	(within) , extra- (outside) , peri - (around) , retro- (behind) , ante- (before/front) , post- (after/behind)
Negation	a-/an- (without) , anti - (against) , contra- (against) , de- (remove/reverse)
Condition	dys- (painful/difficult/abnormal) , eu- (normal/good) , mal - (bad) , pseudo- (false)
Direction	ab - (away from) , ad - (toward) , circum- (around) , ecto- (outside) , endo- (within) , trans- (across)
Speed	brady- (slow) tachy- (fast) ,
OMMON SUFFIXES
MeaningGroup	Suffi xes
Condition	-ia/ -ism (condition/state) -osis (abnormal condition) -itis (inflammation) -emia (blood condition) -algia , , , ,
	(pain) -pathy (disease) -malacia (softening) -megaly (enlargement) -ectasis (dilation) -ptosis (drooping) , , , , , , -
	sclerosis (hardening) -stenosis (narrowing) ,
Surgicalprocedure	-ectomy (surgical removal) , -otomy (incision into) , -ostomy (creating an opening) , -plasty (surgical repair) , -
Diagnostic procedure Specialty	pexy (surgical fixation) -rrhaphy (suturing) -tripsy (crushing) -centesis (surgical puncture) -desis (su 1rgical , , , , fusion) -scopy (visual examination) -graphy (process of recording) -gram (record/image) -metry (measurement) , , , -ology (study of) -logist (specialist) -ician (practitioner) -iatry (medical treatment) , , ,

System	CombiningForms
Integumentary	dermat/oandcutane/o(skin) onych/o(nail) trich/o(hair) adip/o(fat) , , ,
Musculoskeletal	oste/o(bone) arthr/o(joint) my/o(muscle) chondr/o(cartilage) tend/o(tendon) , , , ,
Cardiovascular	cardi/o(heart) angi/o(vessel) ven/o(vein) arteri/o(artery) hem/o(blood) , , , ,
Respiratory	pulmon/o(lung) pneum/o(lung/air) bronch/o(bronchus) trache/o(trachea) , , ,
Gastrointestinal	gastr/o(stomach) enter/o(intestine) hepat/o(liver) col/o(colon) cholecyst/o(gallbladder) , , , ,
Urinary	ren/oandnephr/o(kidney) cyst/o(bladder) ureter/o(ureter) urethr/o(urethra) , , ,
Nervous	neur/o(nerve) encephal/o(brain) cerebr/o(cerebrum) myel/o(spinalcord) , , ,
Endocrine	aden/o(gland) thyr/o(thyroid) pancreat/o(pancreas) , ,

Abbreviations

Common abbreviations include Rx (prescription), Dx (diagnosis), Tx (treatment), Hx (history), Sx (symptoms), NPO (nothing by mouth), PRN (as needed), BID (twice daily), TID (three times daily), QID (four times daily), and STAT (immediately).

Thejointcommission"Donotuse"List

DoNotUse	WriteInstead
U IU ,	"units""internationalunits" ,
QD QOD ,	"daily""everyotherday" ,
Trailingzero(10mg) .	1mg
Missingleadingzero(5mg) .	05mg .
MS MSO MgSO , 4, 4	"morphinesulfate""magnesiumsulfate" ,

The patient interview establishes rapport, gathers health information, and begins the care relationship. It requires communication skills, active listening, and cultural sensitivity.

Component	Content
Chiefcomplaint(CC)	Theprimaryreasonforthevisit recordedinthepatient'sownwords(thecurrentoutlinecallsthis ,
	thechiefconcern)
Historyofpresentillness(HPI)	Detailsofthecurrentproblem:onset location duration character aggravatingfactors relieving , , , , ,
Pastmedicalhistory(PMH) Familyhistory(FH)	factors timing andseverity(OLDCARTS) 1 , , Previousillnesses surgeries hospitalizations injuries andchronicconditions , , , , Geneticandfamilialdiseasepatterns includingcardiovasculardisease cancer diabetes and , , , , mentalillness

Componentsofthehealthhistory(Continued)

Component	Content
Socialhistory(SH)	Occupation lifestyle diet exercise tobacco alcohol anddruguse sexualhistory andliving , , , , , , , ,
	situation
Reviewofsystems(ROS)	A systematic head -to-toe survey of symptoms across all body systems
Medicationsandallergies	Prescription and over-the-counter drugs vitamins supplements and herbal remedies; each allergy , , ,
	withtheallergenandthespecificreaction

Medication reconciliation compares the patient's current list with what the patient actually takes, including new, changed, and discontinued medications, at every visit and transition of care.

Interview Techniques

Open-ended questions ("What brings you in today?") encourage detailed responses in the patient's own words. Closed- ended questions ("When did the pain start?") yield specific or yes/no answers useful for clarification. Facilitation (nodding, eye contact, "go on") encourages the patient to continue; clarification asks follow-up questions; reflection repeats or paraphrases to confirm understanding; and summarization reviews key points so the patient can correct them.

Documentation Principles

The medical record is a legal document and must be accurate, complete, objective, legible, and timely. Record facts, not opinions, and quote the patient's statements when recording subjective information. Correct an error with a single line through it, the date, time, and your initials, followed by the correct entry; never erase, obliterate, or use correction fluid.

Section	Contains	Example
S—Subjective	Whatthepatientreports	"Ihavechestpainthatcomesandgoes" .
O—Objective	Measurable observablefindings ,	P72 R16 BP128/78 , ,
A—Assessment	Theprovider'sdiagnosisorimpression	Possibleangina
P—Plan	Treatment tests education follow-up , , ,	ECGtoday;followupin1week

The problem-oriented medical record (POMR) organizes documentation around the patient's problems. Electronic health records (EHRs) add clinical decision support, order entry, and results retrieval. EHR documentation follows the same principles as paper records, with extra attention to templates and copy-and-paste, which can carry forward information that does not reflect the actual encounter.