Child Life Certification Exam 2022
General Rules for Plurals ** answer **
Common Elements of the Medical Record ** answer ** History and Physical
-written by admitting physician
Details Patient's
-History
-Exam Results
-Initial diagnosis
-Physician's plan of treatment
Common Elements of the Medical Record ** answer ** Physician's Orders
-ordered by the doctor
Complete list of:
-care
,-medications
-tests
-treatments
Common Elements of the Medical Record Notes ** answer ** Nurse's Notes
-Records the patient's care throughout the day
-includes vital signs, treatment specifics, patient's response to treatment, and patient's
condition
Physician's Progress Notes
-Daily record of patient's condition
-results of physical exam, summary of test results, updated assessment and diagnoses,
further plans for treatment.
Common Elements of the Medical Record- Reports ** answer ** Consultation Reports
- Given by a specialist when the physician asks for patient evaluation
Ancillary reports
-From various treatments and therapies
-such as rehabilitation, social services, respiratory therapy, or dietetics
Diagnostic Reports
-Results of all diagnostic tests performed on the patient
- from lab to medical imaging
Common Elements of the Medical Record ** answer ** Informed Consent
-Document voluntarily signed by the patient or responsible party
-clearly describes purpose, methods, procedures, benefits, and risks of procedures
Common Elements of the Medical Record- Reports ** answer ** Operative Report
-From surgeon detailing the operation
-Includes Pre- and Post- operative diagnosis
-Specific details of the procedure and how the patient tolerated the procedure
Anesthesiologist's Report
-Relates details of drugs given to patient
-Response to anesthesia
-Vital signs during surgery
Pathologist's Report
-Report given by pathologist who studies tissue removed from patient
Common Elements of the Medical Record ** answer ** Discharge Summary
-Outline of patient's entire hospital stay
-includes condition at admission, admission diagnosis, test results, treatments, and
patient's response, final diagnosis, and follow-up plans
Confidentiality ** answer ** Health Insurance Portability and Accountability Act of 1996
(HIPAA)
-Any information or record relating to a patient is privileged
-Moral and legal responsibility
,-Proper authorization must be signed by patient before any information can be released
bi/o ** answer ** life
carcin/o ** answer ** cancer
cardi/o ** answer ** heart
chem/o ** answer ** chemical
cis/o ** answer ** to cut
dermat/o ** answer ** skin
enter/o ** answer ** small intestine
gastr/o ** answer ** stomach
gynec/o ** answer ** female
hemat/o ** answer ** blood
immun/o ** answer ** immunity
laryng/o ** answer ** voice box
nephr/o ** answer ** kidney
neur/o ** answer ** nerve
ophthalm/o ** answer ** eye
ot/o ** answer ** ear
path/o ** answer ** disease
pulmon/o ** answer ** lung
rhin/o ** answer ** nose
a- ** answer ** without, away from
an- ** answer ** without
anti- ** answer ** against
, auto- ** answer ** self
brady- ** answer ** slow
de- ** answer ** without
dys- ** answer ** painful, difficult, abnormal
endo- ** answer ** within, inner
epi- ** answer ** upon, over
eu- ** answer ** normal, good
ex- ** answer ** external, outward
extra- ** answer ** outside of
hetero- ** answer ** different
homo- ** answer ** same
hyper- ** answer ** over, above
hypo- ** answer ** under, below
in- ** answer ** not, inward
inter- ** answer ** among, between
intra- ** answer ** within, inside
macro- ** answer ** large
micro- ** answer ** small
neo- ** answer ** new
para- ** answer ** beside, near, abnormal, two like parts of a pair
per- ** answer ** through
peri- ** answer ** around
post- ** answer ** after
General Rules for Plurals ** answer **
Common Elements of the Medical Record ** answer ** History and Physical
-written by admitting physician
Details Patient's
-History
-Exam Results
-Initial diagnosis
-Physician's plan of treatment
Common Elements of the Medical Record ** answer ** Physician's Orders
-ordered by the doctor
Complete list of:
-care
,-medications
-tests
-treatments
Common Elements of the Medical Record Notes ** answer ** Nurse's Notes
-Records the patient's care throughout the day
-includes vital signs, treatment specifics, patient's response to treatment, and patient's
condition
Physician's Progress Notes
-Daily record of patient's condition
-results of physical exam, summary of test results, updated assessment and diagnoses,
further plans for treatment.
Common Elements of the Medical Record- Reports ** answer ** Consultation Reports
- Given by a specialist when the physician asks for patient evaluation
Ancillary reports
-From various treatments and therapies
-such as rehabilitation, social services, respiratory therapy, or dietetics
Diagnostic Reports
-Results of all diagnostic tests performed on the patient
- from lab to medical imaging
Common Elements of the Medical Record ** answer ** Informed Consent
-Document voluntarily signed by the patient or responsible party
-clearly describes purpose, methods, procedures, benefits, and risks of procedures
Common Elements of the Medical Record- Reports ** answer ** Operative Report
-From surgeon detailing the operation
-Includes Pre- and Post- operative diagnosis
-Specific details of the procedure and how the patient tolerated the procedure
Anesthesiologist's Report
-Relates details of drugs given to patient
-Response to anesthesia
-Vital signs during surgery
Pathologist's Report
-Report given by pathologist who studies tissue removed from patient
Common Elements of the Medical Record ** answer ** Discharge Summary
-Outline of patient's entire hospital stay
-includes condition at admission, admission diagnosis, test results, treatments, and
patient's response, final diagnosis, and follow-up plans
Confidentiality ** answer ** Health Insurance Portability and Accountability Act of 1996
(HIPAA)
-Any information or record relating to a patient is privileged
-Moral and legal responsibility
,-Proper authorization must be signed by patient before any information can be released
bi/o ** answer ** life
carcin/o ** answer ** cancer
cardi/o ** answer ** heart
chem/o ** answer ** chemical
cis/o ** answer ** to cut
dermat/o ** answer ** skin
enter/o ** answer ** small intestine
gastr/o ** answer ** stomach
gynec/o ** answer ** female
hemat/o ** answer ** blood
immun/o ** answer ** immunity
laryng/o ** answer ** voice box
nephr/o ** answer ** kidney
neur/o ** answer ** nerve
ophthalm/o ** answer ** eye
ot/o ** answer ** ear
path/o ** answer ** disease
pulmon/o ** answer ** lung
rhin/o ** answer ** nose
a- ** answer ** without, away from
an- ** answer ** without
anti- ** answer ** against
, auto- ** answer ** self
brady- ** answer ** slow
de- ** answer ** without
dys- ** answer ** painful, difficult, abnormal
endo- ** answer ** within, inner
epi- ** answer ** upon, over
eu- ** answer ** normal, good
ex- ** answer ** external, outward
extra- ** answer ** outside of
hetero- ** answer ** different
homo- ** answer ** same
hyper- ** answer ** over, above
hypo- ** answer ** under, below
in- ** answer ** not, inward
inter- ** answer ** among, between
intra- ** answer ** within, inside
macro- ** answer ** large
micro- ** answer ** small
neo- ** answer ** new
para- ** answer ** beside, near, abnormal, two like parts of a pair
per- ** answer ** through
peri- ** answer ** around
post- ** answer ** after
