Chapter 12: Communication
Katie Baker
Having the ability to create documentation of patient end provider interactions quickly and accurately is one of the most important skills for a healthcare professional to have. Using medical shorthand, healthcare providers can engage in recording of visits and patient conversation simultaneously. It is important that approved abbreviations are used. Many times, this approval will come from a professional organization but medical institutions may also publish a list of abbreviations used at their facilities. This is to prevent misinterpretations and medical errors.
Terms Relating to Anatomy And Physiology
Historically, professional terminology provided a way in which members of the same profession could communicate with one another more precisely. However, it also had a gatekeeping function which prevented members of the general public from understanding topics on the same level as professionals. During the times of early exploration and discovery of the human body in Western society, higher education was provided in Latin and Greek and limited to white men of higher socioeconomic standing. Hence, many anatomical and physiological terms used today come with a Latin or Greek root word.
Other historical medical terms were named after the Western men who “discovered” a body part or a condition. These terms are in the process of being renamed to be more descriptive and to improve communication between providers of varying backgrounds. For example, the sphincter of Oddi, located in the duodenal wall of the small intestine, is the site of secretion of pancreatic juices and bile, formed in the liver and stored in the gallbladder. As such, it has been renamed the hepatopancreatic sphincter to indicate its two sources, the liver (hepato-) and the pancreas.
More recent language changes, like the shift towards and then away from person-first language for autistic individuals, and the movement towards using gender-neutral terminology to be inclusive of trans individuals, have been highly beneficial for improving communication between patient and provider. For example, the term “women” is commonly used to describe people with uteruses. However, when we are providing care to individuals with uteruses, an individual’s gender identity may not be accurate to properly communicate who is being treated. In this example, the term “women” excludes trans men with intact uteruses, and inappropriately assigns a uterus to individuals who are cis-gendered women post-hysterectomy, and trans women. As a medical community we are beginning to incorporate these best practices into medical communication and language.
Increasingly, lay language, or common language, is being used to refer to anatomy and physiology when speaking with patients. This is another practice to improve a patient’s understanding of their own health. That being said, it is still very important to utilize medical terminology when charting or discussing a patient complaint with other providers to ensure that both individuals mean the same thing.
In Appendix 8, you will find a table with common regional and systemic anatomical terms as well as their definition. you will see that certain Greek and Latin prefixes are used to refer to different body systems. This can help you to decode unfamiliar terms by using your new knowledge of the related root words to place a term in a specific system.
A system using abbreviations and symbols to take written or typed notes more rapidly.