DOH Allied Health Exam key terms

A patient's voluntary agreement to a procedure or treatment after receiving and understanding information about its purpose, risks, benefits, and alternatives. It must be given by a competent person without pressure.

The range of duties, tasks, and responsibilities a health worker is legally and professionally permitted to perform based on their training, certification, and employer policy. Working outside it can endanger patients and create legal liability.

The assignment of a specific task to another worker while the delegating professional retains accountability for appropriate supervision and for judging whether the task suits that person's training.

The ethical and legal duty to protect a patient's private health information from unauthorized disclosure. Information may be shared only with those involved in care or as permitted by law or patient authorization.

A United States federal regulation that sets standards for protecting individually identifiable health information and defines when disclosure is permitted, such as for treatment, payment, and health care operations.

A legal document in which a person states health care preferences or names someone to decide for them if they become unable to communicate. Examples include living wills and durable powers of attorney for health care.

A written medical order, authorized by the patient or their legal decision-maker, directing that CPR not be attempted if the patient stops breathing or their heart stops. It must be verified before withholding resuscitation.

Failure to provide the level of care a reasonably prudent professional would provide in similar circumstances, resulting in harm. Proving it generally requires a duty, a breach, causation, and damages.

A legal requirement that health workers report certain events to authorities, such as suspected child or elder abuse, communicable diseases, or serious workplace injuries, even without patient permission.

Standard measurements of body function: temperature, pulse, respiratory rate, blood pressure, and often oxygen saturation and pain. They are used to detect changes in a patient's condition and guide care decisions.

The force exerted by circulating blood against artery walls, recorded as systolic pressure over diastolic pressure in millimeters of mercury. It reflects cardiovascular function and fluid status.

A noninvasive method of estimating the percentage of hemoglobin saturated with oxygen in arterial blood using a probe on a finger, ear, or toe. Readings can be affected by poor circulation or nail products.

Practices that keep equipment and wounds free of microorganisms during procedures, such as hand hygiene, sterile gloves, and avoiding contact with nonsterile surfaces. Used for invasive procedures and wound care.

Cleaning hands with soap and water or alcohol-based rub at specified moments, such as before and after patient contact and after removing gloves. It is the single most effective way to prevent transmission of infection.

Barriers worn to protect the worker and patient from exposure to infectious agents or hazardous materials, including gloves, gowns, masks, respirators, and eye protection. Selection depends on the anticipated exposure.

Infection control measures applied to all patients regardless of diagnosis, including hand hygiene, gloves, gowns, and safe handling of sharps and body fluids. They assume any blood or body fluid may be infectious.

Extra measures used in addition to standard precautions for specific infections, grouped as contact, droplet, and airborne precautions. They may include isolation rooms, dedicated equipment, and specific masks.

A designated work area where only sterile items are permitted and contact with nonsterile objects is avoided. It is maintained during procedures such as catheter insertion or dressing changes to prevent contamination.

An accidental puncture or cut from a needle, scalpel, or other contaminated sharp object. It requires immediate washing, reporting, and evaluation for post-exposure prophylaxis against bloodborne pathogens.

A microorganism present in blood or body fluids that can cause disease when transmitted, such as hepatitis B, hepatitis C, and HIV. Prevention relies on standard precautions and safe handling of sharps.

The body's tendency to maintain stable internal conditions, such as temperature, pH, and blood glucose, through continuous regulatory adjustments. Illness often reflects a disruption of these balancing mechanisms.

A control mechanism in which a change in a body variable triggers a response that reverses that change, returning the variable toward its normal range. It is the most common form of physiological regulation.

Persistently elevated arterial blood pressure, generally at or above 130/80 millimeters of mercury in adults. It is often symptomless but increases the risk of stroke, heart disease, and kidney damage.

A condition in which body tissues receive an inadequate supply of oxygen. Signs may include shortness of breath, confusion, rapid heart rate, and low oxygen saturation readings.

Swelling caused by accumulation of fluid in body tissues, often seen in the legs, ankles, or lungs. It can result from heart, kidney, or liver disease, injury, or prolonged immobility.

The body's local response to injury or infection, characterized by redness, heat, swelling, pain, and sometimes loss of function. It helps contain damage and begin repair.

The invasion and multiplication of microorganisms in body tissues, which may produce symptoms such as fever, pain, or discharge. Treatment depends on the causative organism and site.

A word part attached to the beginning of a root term that changes or qualifies its meaning, such as tachycardia meaning fast heart rate. Recognizing prefixes helps interpret unfamiliar clinical terms accurately.

A word part added to the end of a root term that indicates a condition, procedure, or process, such as -itis for inflammation. It often determines the grammatical category of the term.

The core word part that carries the primary meaning of a medical term, usually referring to a body part or system, such as cardi for heart. Combining vowels often link roots to suffixes.

Recording of observable, measurable findings such as vital signs, test results, and visible symptoms, rather than personal opinions. It supports accurate communication and legal defensibility of care.

Recording of information the patient reports, such as pain level, symptoms, and history, often in their own words. It is clearly distinguished from measurable findings obtained by the clinician.

The formal, ongoing documentation of a patient's care, including assessments, treatments, medications, and communications. It serves as a legal record, supports continuity of care, and is used for billing and quality review.

The process of comparing a patient's current medication list with new orders and prior records to identify discrepancies, duplications, or omissions. It is performed at transitions of care to prevent errors.

A safety checklist confirming the right patient, right drug, right dose, right route, and right time before giving a medication. Many facilities add right documentation and right reason.

An unintended, harmful response to a medication given at a normal dose. It differs from a medication error and should be documented and reported to the appropriate monitoring system.

A severe, rapidly developing allergic reaction that can cause airway swelling, difficulty breathing, falling blood pressure, and shock. It is a medical emergency requiring immediate epinephrine and emergency services.

Emergency chest compressions and rescue breaths used to maintain circulation and oxygenation when a person's heart has stopped or they are not breathing normally. It is started immediately and continued until advanced help arrives.

A model describing the six linked elements needed for infection to spread: pathogen, reservoir, exit portal, mode of transmission, entry portal, and susceptible host. Breaking any link prevents transmission.

Purposeful interaction that uses active listening, open-ended questions, empathy, and clarification to support a patient's understanding and emotional needs. It builds trust and improves information exchange.

Fully concentrating on a speaker, noticing verbal and nonverbal cues, and reflecting back understanding without interrupting. It reduces misunderstandings and strengthens the therapeutic relationship.

A person's ability to obtain, understand, and use health information to make decisions. Low health literacy requires plain language, teach-back, and visual aids to ensure understanding.

A communication technique in which the patient explains instructions in their own words to confirm understanding. It reveals gaps and allows the clinician to re-educate before the patient leaves.

The formal line of authority and communication within an organization that defines whom to notify and who makes decisions. Following it ensures timely escalation during routine care and emergencies.

The transfer of patient information and responsibility between caregivers using a structured format such as SBAR. Clear handoffs reduce omissions and errors at shift changes and transfers.