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Accuracy & Abbreviations in Medical Terminology

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Instructor: Adrianne Baron

Adrianne has a master's degree in cancer biology and has taught high school and college biology.

Medical terminology is often considered an entirely new language, full of lengthy terms from various languages. Learn the importance of accuracy and abbreviations in medical terminology for producing efficient and safe practice among medical personnel. Updated: 11/07/2021

Medical Terminology

Medical terminology is often seen as a completely new language, referred to as the 'Language of Medicine.' The language is composed of terms that are derived from many different other languages to include Latin, English, and Greek. The terms can be very lengthy and look extremely foreign at first glance until you become more acquainted with the language. Eventually, you'll get to the point that you are as familiar with the terms and how to use them as you are with your first language. As you are learning medical terminology, the value of abbreviations will become apparent to you as will the importance of accuracy when using this language.

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Accuracy in Medical Terminology

Think about this scenario for a minute. You are a patient in a specialist's office, and you are awaiting a report from the doctor to let you know some test results and about possible treatments to correct some stomach discomfort you have had that makes it hard to eat. The door opens, the specialist comes in and opens your chart. The specialist reads the results from your regular doctor's office and lets you know the report says that you need to have a gastrostomy, meaning they need to create an opening into your stomach for a feeding tube. You are puzzled! You knew you were experiencing some difficulties, but didn't think it was serious enough for that to be done.

You have the procedure done, and afterward, the specialist lets you know that once inside, there wasn't anything he could see that could be the reason for needing the gastrostomy. Upon consulting with your regular doctor, it was determined that you were supposed to have a gastrotomy, meaning an incision into your stomach to remove some excess stomach acid. Oops! That's a very big oops, though! It was misspelled in your chart. There's a huge difference between a simple incision to remove some fluid and having an opening made in your stomach with a tube coming to the outside of your body for you to eat through!

There isn't much of a difference though between the spelling of gastrostomy and gastrotomy. In fact, it's only a one letter difference! Accuracy in spelling and pronunciation is an absolute must in medical terminology. One letter, or a couple of letters, can be the difference between a simple diagnosis and a life-threatening diagnosis. A mistake involving a few letters can be the difference between keeping and losing a part of the body. For instance, I could take gastrotomy and change only a few letters and make gastrectomy, meaning removal of the stomach. Could you imagine waking up to find out that your stomach was removed instead of just being cut into?

Aside from how accuracy affects patients, there are legal ramifications as well. Every patient chart is considered to be a legal document. It could be needed should there ever be an investigation into the office or the doctor's practices. The doctor's malpractice insurance usually requires that the charts are completely accurate, too. This will be of the utmost importance to the doctor's attorney since the charts will be needed in order to defend the doctor.

There are other legal cases for which a patient's chart may be needed in court. For example, it could potentially come into play during a divorce proceeding if any part of the grounds for divorce are based on anything contained in the health record. This could include documentation that a sterilization procedure was done prior to getting married or diagnosis of an STD. It is only useful in court if everything in it is completely accurate. In the unfortunate event that the patient is found dead, the chart could be needed in order to help identify their body.

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