Medical Terminology and Documentation
Core concepts
Terminology questions test word roots, prefixes, and suffixes, plus abbreviations common in clinical records. Learn to decompose terms: prefix (location, number, timing) + root (organ or tissue) + suffix (condition or procedure). Documentation questions test accuracy, completeness, timeliness, objectivity, and confidentiality. Understand what belongs in a record - objective findings, interventions, patient responses, and time stamps - and what does not (opinions, blame, speculation). Know the difference between subjective and objective data and the meaning of "if it wasn't documented, it wasn't done."
Traps
Distractors use near-miss abbreviations or reversed prefixes (hyper- vs hypo-, brady- vs tachy-). Documentation traps include charting a conclusion instead of an observation ("patient was rude" vs. quoting what was said), late entries without notation, and altering a record after the fact. Watch for questions asking what to do when you made a documentation error - the answer is a single line-through with initials, date, and correction, never erasure or overwriting.
Rule of thumb
Objective-over-opinion rule: document what you saw, heard, measured, and did - not your interpretation of the patient's character. If you can't measure or quote it, describe it factually.
Worked example
Instead of "patient was uncooperative," chart: "Patient declined the 1400 medication, stating, 'I don't want it right now.' Provider notified at 1405; patient's statement documented." This is objective, timed, and actionable.