Terminologies in Medical Records
Name
Institution
Medical records include the lifetime record of a patient’s health, health problems, and medical care at a particular institution. The medical history of a patient involves the history including information such as allergies, medications being taken, social history past medical history and family history. Different medical encounters are outlined as where the patient providers visit is discussed and a physical examination is performed.
| Front | Back |
| Condition develops slowly over time | chronic |
| Severe symptoms for a shirt while | acute |
| Measure of prevention | prophylaxis |
| harmful | malignant |
| Gradual deterioration of normal cells and body functions | degeneration |
| sick | morbidity |
| Diagnostics based on evaluation of symptoms ,signs and test findings | diagnosis |
| Study of disease cause | etiology |
| significant | marked |
| Abate | remission |
| Relating to the whole body | systemic |
| No identified cause of illness | idiopathic |
Health care terminologies in medical recording involve the financial management of healthcare, health insurance and the involvement of healthcare systems. Abbreviations, acronyms and medical terminologies are involved e.g. ALL, AMI, FSH, HPS, MDS, PE, SIDS, TSH, IBS etc. The importance of medical terminologies includes:
- Standard communication between professionals.
- It makes it easy to avoid errors
- Allows easy documentation and communication
Primary coding involves coding of medical data at time of consultation by health worker while secondary coding buts its time consuming , requires major training for standardization and limits medics expression on registry input with high resistance in use. Secondary coding involves coding of data by various physicians which is very viable in use. It is also true that computerized coding is more efficient than manual coding by fact of time saving and higher quality coding by the virtue of text-autocoding.Involvement of electronic health records (EHR) and electronic medical records (EMR) allows for a good health information exchange.
References
“A Sample Health Record”. Nlm.nih.gov. Retrieved 2012-04-14.
“Personal Health Records” (PDF). CMS. April 2011. Archived from the original (PDF) on 2012-03- 05. Retrieved 2012-04-14.