Common medical terminology comes of age, Part Two: Current code and terminology sets--strengths and weaknesses

J S Rose1, B J Fisch, W R Hogan

  • 1Health Language Inc., Aurora, Colorado, USA.

Related Concept Videos

Anatomical Terminology01:20

Anatomical Terminology

Knowledge of anatomy is essential to understand human biology and medicine. Anatomists and health care professionals use standard terminology to describe the human body with more precision and no ambiguity. Anatomical terms have mostly Greek and Latin-derived roots. Because these languages are rarely used in conversation, the meaning of words remains the same. Each term is made up of a root in between the prefixes and suffixes. The root of a term often refers to an organ, tissue, or condition,...
Regional Terms01:12

Regional Terms

Regional terms describe anatomy by dividing the body parts into different regions that contain structures involved in contributing similar functions. Using these terms helps increase the accurate description and identification of the particular region of interest or region affected by the disease.
Primarily, the human body has two major regions, the axial and appendicular regions. The axial region comprises regions from the head to the abdomen and makes up the central body axis. In contrast,...
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Standards of Care I01:22

Standards of Care I

Federal statutes profoundly impact nursing practice, providing critical guidelines to ensure patient care is equitable, accessible, and of the highest quality. The following laws address distinct aspects of healthcare provision and patient rights:
Standards of Care II01:19

Standards of Care II

Nurses bear specific legal responsibilities under several federal statutes, including: