PAC 115 Module 2 Building and Decoding Terms Example

Reading the Record Before the First Session: Building and Decoding the Terms in a Discharge Summary

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 115: Medical Terminology

Instructor Name

Month Day, Year

Reading the Record Before the First Session: Building and Decoding the Terms in a Discharge Summary

Before a first appointment, an addiction counselor often receives records from a client's recent hospital stay. For a composite client, a 46-year-old man referred to outpatient treatment after five days in the hospital, the discharge summary reads in part: admitted with alcohol withdrawal and tachycardia; history of hypertension and gastroesophageal reflux; hepatomegaly on examination; labs showed hypokalemia and thrombocytopenia; treated with a benzodiazepine taper; discharged with a referral for outpatient care. This paper applies the word-building system from Module 1 to decode the summary's terms, shows how the same parts build other terms, and explains how a counselor can turn a decoded record into good questions for the treatment team.

The Method, Briefly

Decoding moves from the end of a word to the beginning: identify the suffix, then any prefix, then the root or roots, and assemble the meaning. When a term contains two roots, the one closer to the suffix is usually the part being described. The method works for most clinical terms because they were built deliberately from Greek and Latin parts.

Ten Terms From the Summary

The table decodes ten terms from the discharge summary and offers a plain-language version of each.

Building From the Same Parts

Once a part is known, it unlocks other terms. The suffix emia in hypokalemia appears in hyponatremia, low sodium, and hyperglycemia, high blood sugar. Penia in thrombocytopenia appears in leukopenia, low white cells, and neutropenia, low neutrophils. Megaly appears in splenomegaly and cardiomegaly. Building terms from parts this way turns one decoded word into a family of words, which is far more efficient than memorizing each separately.

Terms That Do Not Decode

Not every term yields to the method. Drug class names such as benzodiazepine come from chemistry, not anatomy. Eponyms, terms named after people, such as Korsakoff syndrome, carry no meaning in their parts. And some clinical terms are ordinary English words with specialized meanings: withdrawal, taper and remission all mean something precise in a record. For these, a reliable medical dictionary or the treatment team is the right source.

Checking Before Assuming

A counselor should check any term whose meaning affects care. Look-alike terms, such as hypokalemia and hyperkalemia, differ by one prefix but point in opposite directions. Abbreviations in the record may have several meanings. And a counselor who misreads a medical term may give a client incorrect information, which harms trust and possibly health.

Why Plain Language Matters to Clients

Clients themselves often misread the language in their records. When researchers compared how people understood jargon and plain phrasing, plain versions were understood better in every pair they tested, and some terms that clinicians use as good news were widely taken as bad (Gotlieb et al., 2022). Among emergency department patients, understanding of words such as acute and benign was poor (Wahrenbrock et al., 2025). Low health literacy is linked to more hospital use and poorer self-care (Berkman et al., 2011), so a counselor who can explain a record in everyday words helps the client understand their own health.

From Decoding to Questions

Decoding the summary gives the counselor several questions for the treatment team and, with the client's consent, for the discharging physician. Is the enlarged liver being followed up? Have potassium and platelet levels been rechecked? Does the fast heart rate reflect withdrawal alone or another problem? Which medications was the client discharged on? These questions show respect for the client's whole health and support the coordination that addiction treatment requires.

A Second Example

The method works on the rest of the summary too. The record's medication list includes thiamine and folic acid, vitamins rather than terms to decode, but the reason for them appears in a note that the client has macrocytosis, from macro, large, cyt, cell, and osis, condition: larger than normal red blood cells, a finding often associated with heavy drinking and low folate. A progress note describes paresthesia in both feet, from para, abnormal, and esthesia, sensation: tingling or numbness, which in a heavy drinker may point to nerve damage. Each decoded term adds to the counselor's picture of the client's health.

Decoding also shows what is missing. The summary never mentions sleep, mood or the client's own goals, which are central to counseling. A decoded record is a starting point for a conversation, not a complete picture, and the counselor's first session fills in what the medical record could not.

Questions like these should be asked with care for the client's privacy. The counselor confirms that the client has signed a release before contacting the hospital, shares only what is needed, and records in the chart what was asked and what the team answered, so that the next counselor who reads the file can follow the thread.

Conclusion

A discharge summary that looks forbidding becomes readable when its terms are decoded part by part. Ten terms from one composite summary show the method working, and the same parts unlock many other words. Some terms, such as drug names and eponyms, require a dictionary, and any term that affects care should be checked. Decoding also prepares the counselor to translate the record for the client and to ask the treatment team informed questions.

References

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97-107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005

Gotlieb, R., Praska, C., Hendrickson, M. A., Marmet, J., Charpentier, V., Hause, E., Allen, K. A., Lunos, S., & Pitt, M. B. (2022). Accuracy in patient understanding of common medical phrases. JAMA Network Open, 5(11), Article e2242972. https://doi.org/10.1001/jamanetworkopen.2022.42972

Wahrenbrock, T., Landry, K., Amin, D. P., Rizvanolli, L., Chandrasekaran, R., Mycyk, M. B., & Routsolias, J. C. (2025). Medical jargon is often misunderstood by emergency department patients. The American Journal of Emergency Medicine, 96, 25-29. https://doi.org/10.1016/j.ajem.2025.06.012