As a medical assistant, having a solid understanding of medical terminology is essential to communicate effectively with other healthcare professionals and provide quality care to patients.
In this comprehensive guide, we will cover everything you need to know about medical assistant terminology, from common abbreviations to specialized medical terms.
Common Medical Terminology
When it comes to common medical terms, there are three determining features.
- Prefix – found at the beginning of a term
- Suffix – located at the end of a term
- Root word – helps identify what part of the body the condition refers to
Learning how these features operate will help medical assistants become proficient in using the common medical terms found in healthcare facilities.
- A or An: means without
- Anti: means against
- Dis: meaning reversed or separated
- Dys: refers to something being painful, difficult, or abnormal
- Exo: meaning outside
- Hyper: meaning excessive or high
- Hypo: meaning below, or less than normal
- Inter: meaning between
- Intra: meaning inside
- Para: meaning alongside
- Poly: meaning many or a lot
- Sub: meaning beneath
- -ectomy: refers to the surgical removal of a body part
- -emia: refers to a blood condition
- -itis: refers to inflammation of a body part
- -pathy: refers to a disease or disorder
- -phobia: refers to a psychological fear of a specific thing
- -physis: refers to abnormal growth
- -plegic: refers to partial or full paralysis
- -ology: refers to the specific study or field of medicine
- -oma: refers to a tumor or growth
- -osis: refers to the abnormal condition or disease
- -rrhage: meaning the excessive flow/discharge of fluid in or from the body
- -thermic: relating to temperature
- -tomy: refers to the cutting into a body part or organ
Common root words
Root words can appear at the beginning or in the middle of a term.
Common roots word include:
- Arterio: artery
- Carcino: cancer
- Cardio: heart
- Derm: skin
- Gastro: stomach
- Neuro: nerve
- Osteo: bone
- Cranio: skull
- Adreno: adrenal glands
- Arthro: joints
- Pneumo: lung
- Musculo: muscle
Basic anatomy and physiology terminology
- Medial: towards the body’s midline
- Lateral: away from the body’s midline
- Anterior: in front
- Posterior: at the back
- Proximal: closer to the origin
- Distal: further away from the origin
- Superior: higher up
- Inferior: lower down
- Sagittal Plane: vertical line that divides the body into two equal sections (left and right)
- Coronal Plane: verticle line that divides the body into front and back sections
- Transverse Plane: horizontal line that divides the body into upper and lower sections
Common medical abbreviations
- BMI: body mass index
- BP: blood pressure
- CBC: complete blood count
- EKG/ECG: electrocardiogram
- HBP: high blood pressure
- HR: heart rate
- MRI: magnetic resonance imaging
- P: pulse
- RR: respiratory rate
- T: temperature
- US: ultrasound
- VS: vital signs
Specialized Medical Terminology
Depending on their place of work, there is medical assistant terminology that is specific to specialists (e.g dermatology, ophthalmology, cardiology). MAs who specialize in their medical assisting career will need to be familiar with the particular medical terms pertaining to their specialization.
Even if a medical assistant does not specialize, there will be times when more complex terminology will be used.
This includes terminology around:
- medical instruments & equipment (e.g different clamps, forceps, sutures, etc.)
- diagnostic & laboratory tests (e.g. sarcoma, polyp, benign, etc.)
- medical procedures & surgical terms (e.g biopsy, bypass, skin graft, etc.)
Electronic Health Records Terminology
An electronic health record (EHR) is a digital file that contains the entire medical history of a patient. It stores important health information such as past illnesses, current conditions, prescribed medications, immunizations, and pathology test results.
EHRs also contain billing details and financial information that is essential for the insurance claims process. Inaccurate data could result in insurance claims being returned or denied which is costly for the health care provider.
Common EHR terminology includes:
- Accountable care organizations
- Allowable costs
- Electronic data interchange
- Health maintenance organizations
- Health savings account
- Lifetime limit
- Out-of-pocket costs
- Preferred provider organization
Communication in Healthcare
The top three successful components for a medical assistant to master is:
- Active listening
- Verbal communication
- Nonverbal communication
Medical assistants need to act with the utmost professionalism when working with doctors and other healthcare personnel. This will help avoid miscommunications and errors in patient care.
When it comes to communicating with patients and family members, medical assistants have the acquired communication skills and vast technical knowledge needed to relay information from other medical professionals, address patient concerns, and educate on patient care.
Their role is crucial for making sure that patients feel listened to and well taken care of throughout their care journey.
Being mindful of the various communication barriers will help make medical assistants better communicators and avoid communication breakdowns.
There are several communication barriers to consider:
To overcome any of these barriers, it is key for medical assistants to approach patients with empathy and compassion. They also need to tackle problems with critical thinking and creative problem-solving techniques.
There are many terms that a medical assistant needs to know to be effective at their job.
This is because medical assistant terminology makes up a large part of the essential communication skills needed to work as a medical assistant.
Mastering the various terms and using them correctly ensures the efficient transmission of information between all healthcare workers.
What is the difference between ICD-10 and CPT codes?
Both codes are used in the billing part of healthcare but have slightly different meanings.
Current Procedural Terminology (CPT) is the main coding system used to bill insurance companies. Each CPT code has a corresponding monetary value for the medical procedure used in patient care. Insurance companies rely on CPT codes to process claims and determine expenses covered.
International Classification of Disease codes (ICD-10) is a globally recognized set of codes used by the World Health Organization that represents common diseases and disorders.
In medical billing, the ICD code is paired with the CPT code to indicate what diagnosis or condition the treatment is being billed for.
Knowing both sets of codes is essential for the administrative tasks that a medical assistant undertakes.
What is the most common medical abbreviation used by medical assistants?
Because medical assistants do the initial intake examination of a patient, their most commonly used terms would be related to checking a patient’s vital signs.
The two most common abbreviations used are BP for blood pressure and TRP for temperature, respiration (breathing), and pulse.
What are some common medical terms used in obstetrics and gynecology?
The most common medical terminology specifically related to obstetrics and gynecology are;
- Breech: the feet first position of a fetus, instead of head first
- Caesarian section (C/S, c-section): a surgical process to deliver a fetus through an incision in the lower abdomen
- Cerclage: a surgical procedure where a suture is used to close the cervix to delay birth/avoid miscarriage
- Dilation and curettage (D&C): a procedure used in surgical abortions or after a miscarriage where the cervix is widened and an instrument is inserted to remove the uterus lining
- Eclampsia: a serious gestation condition where the patient suffers from hypertension. Extreme risk of coma, convulsions, and death.
- Ectopic pregnancy: when a fertilized embryo implants into the fallopian tube instead of the uterus.
- Episiotomy: a surgical procedure done during delivery where an incision is made to widen the vaginal to prevent muscle/skin tearing.
- Endometriosis: a painful condition in which uterine lining tissue is found outside of the uterus in the ovaries, fallopian tubes, outer cervix, etc.
- Hysterectomy: the surgical removal of the uterus. A total hysterectomy includes ovaries, fallopian tubes, and cervix.
- Induction: the procedure to start labor, either done medically or surgically.
- Preeclampsia: a serious condition where the mother experiences unusual hypertension, swelling, and proteinuria.
What is a SOAP note?
SOAP is an acronym for Subjective, Objective, Assessment, and Plan. It is a widely accepted format that healthcare workers use for collecting patient information.
It functions as a way to track the progress and recovery of a patient. It is done in such a manner that allows collaborative healthcare providers to read a patient’s chart without confusion.
What is HIPAA and how does it relate to medical terminology?
HIPAA refers to the Health Insurance Portability and Accountability Act of 1996, which is a U.S. federal law centered around the privacy of patient health information.
It ensures that any medical information cannot be shared with anyone unless it is done with the full consent of the patient.
HIPAA relates to medical terminology as it is the primary format and language in which private health information is recorded.
It also relates to the medical assisting field as it is MAs that are primarily responsible for collecting health information from patients. They must abide by the HIPAA act and make sure that they are not revealing any information (either voluntarily or involuntarily).