Identify misspelled medical terms found in a patient’s operative report. Use the template to correct the terms’ spelling and translate them into common terms. Write a 1-2 page paper that describes the purpose and contents of some of the types of documentation used in the HIM field. Specify the settings in which these documents would be used.
In this fourth assessment, we continue our focus on medical terminology, specifically on medical terminology related to the genitourinary system. This includes the urinary system and the male and female reproductive systems. The urinary system is also known as the renal system. It is a group of organs that filter excess fluid and other blood stream substances from the body.
This assessment consists of two parts. In Part One you will review an operative report. During this course you have already examined a progress note and an H&P. In the operative report you review as part of this assessment, you will translate the medical terms you find into common terms. You will also correct spelling errors that appear in the report. Completing this portion of the assessment will allow you to demonstrate your knowledge of how the genitourinary system works. You will also demonstrate your knowledge of diseases, treatments, and diagnostic tests associated with this important body system.
In Part Two, you will write a one-to-two-page paper that analyzes the different types of documentation in the health record. Familiarity with the contents and use of each type of documentation is an important aspect of your role as a HIM professional.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
- Identify medical terms related to general structures and functions of the human body correctly.
- Translate medical terms related to general structures and functions of the human body into common terms correctly.
- Competency 3: Use medical terminology and abbreviations related to body systems.
- Identify medical terms related to body systems correctly.
- Translate medical terms related to body systems into common terms correctly.
- Competency 5: Analyze and define medical terminology as used in health information management.
- Describe the purpose and contents of some of the types of documentation that are part of the health record.
- Identify settings where the documentation is used.
- Competency 6: Spell and pronounce basic medical terms.
- Identify misspelled medical and common terms.
- Spell medical and common terms correctly.
- Competency 7: Communicate in a professional manner.
- Write clearly, with correct spelling, grammar, and syntax, and good organization.
- Provide citations and references in APA style.
Instructions
Part One: Operative Report
Carefully review the operative report for a patient who is having a sling replacement to treat urinary frequency and incontinence. Next, download the Operative Report Template [DOCX] and complete all of the following on the template:
- Select 15 misspelled medical terms in the operative report and place them in Column 1.
- Translate the 15 misspelled medical terms into commonly used terms in Column 2 correctly.
- Place the correctly spelled medical term in Column 3.
- Cite in correct APA style the references you used to perform your translation.
Preoperative Diagnosis: Urinary stress incontinence, cystocele.
Postoperative Diagnosis: Same.
Anesthesia: General.
History: This is a 49-year-old female with a history of a histerectomy and bilateral ophorectomy. She complains of urinarie frequency and incontinental. Options were discussed with patient, and she decided to proceed with a sling placement. Risks of the procedure were discussed. They include hemorhage, UTI, pielonephritis, cystitis, vaginitis, MI, DVT, PE, death, et cetera, and were deemed acceptable.
Operative Details: The patient was brought to the ER positioned, prepped and draped in the usual fashion. Time-out was called and patient identity and procedure being performed was validated. A Folley catheter was placed, and the bladder drained. Allis clamps were placed on the posterior vaginal muosa. A small incision was made, and the blader was lifted off of the vaginl mucosa. The cystcele was reduced. At this time, a minor enterocele was noted. Due to the small size, the interocele was not repaired. Bilateral stab incisions were made suprapublically and SPARC needs placed into the superpubic incisions and pulled through the vaginal incisions. The SPARC mesh was attached to the needles and pulled up through the insicions. The mesh was positioned against the mid-urethre, sutured into place, and cut below the surface of the sin. The skin was closed with 4-place suture; the vaginal incision was closed with 0-vicryl. The patient was transferred to the recovery room in stable condition.
Blood Loss: Minimal.
Part Two: HIM Terminology
Write a short, one-to-two-page paper on some of the types of documentation used in the HIM field. Be sure your paper includes all of the following headings:
- Progress Note.
- History and Physical (H&P).
- Operative Report.
- Discharge Summary.
Under each heading, address each of the following:
- Describe the purpose of the document.
- Detail the contents included.
- Identify settings where the document would be used.
Consult the Capella Writing Center as needed for additional writing resources to help your write the paper portion of your assessment.
Additional Requirements
Part One: Operative Report
- Format: Ensure you complete all columns on the Operative Report Template.
- Scoring Guide: Be sure to read the scoring guide for this assessment, so you understand how your faculty member will evaluate your work.
Part Two: HIM Terminology
- Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
- Title Page: You do not need to include a title page with your paper. You do need to label it HIM Terminology.
- Name: Include your name in the upper right-hand corner on your paper.
- Length: Approximately 1–2 typed and double-spaced content pages in Times New Roman, 12-point font, not including the reference page.
- References: Include a minimum of one citation of peer-reviewed sources in APA format.
- Resources: The Genitourinary Systems
Genitourinary Systems
Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders. Available from the Bookstore.
- Chapter 7, “Urinary System,” pages 215–256.
- Chapter 8, “Female Reproductive System,” pages 257–310.
- Chapter 9, “Male Reproductive System,” pages 311–342.
- Resources: The Endocrine System
The Endocrine System
Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders. Available from the Bookstore.
- Chapter 18, “Endocrine System,” pages 749–798.
- Resources: Word Structure
Word Structure
Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders. Available from the Bookstore.
- Appendix I, “Plurals,” page 981.
- Resources: Health Information Management (HIM) Terminology
Health Information Management (HIM) Terminology
- Casto, A., Koehler, M., & Lockwood, F. (2017). Clinical terminology: Expanding career pathways for HIM professionals. Journal of AHIMA, 88(9), 50–55.
- Russo, R. (2004,October). Documentation and data improvement fundamentals. IFHRO congress & AHIMA convention proceedings. Retrieved from
Expert Solution Preview
Introduction:
As a medical professor responsible for creating college assignments and evaluating student performance, it is important to focus on medical terminology and documentation in the health information management (HIM) field. In this assessment, we will be assessing the student’s proficiency in identifying misspelled medical terms, translating them into common terms, recognizing and analyzing the different types of documentation used in the HIM field, and understanding the purposes of those documents and their respective settings.
Part One: Identifying Misspelled Medical Terms
In the operative report presented, there are several misspelled medical terms. The misspelled medical terms are identified and corrected in the Operative Report Template. The translations of those identified terms into commonly-used terms may help better understand the genitourinary system, along with its associated diseases, treatments, and diagnostic tests.
Part Two: Types of Documentation in the HIM Field
Documentation in the health record is crucial for healthcare providers to deliver high-quality care to their patients. Here is a brief overview of some of the types of documentation used in the HIM field:
1. Progress Note:
A progress note is a chronological, descriptive record of a patient’s care that documents progress towards the patient’s goals. It includes information on the patient’s diagnosis, treatment plan, medications, and progress. This type of documentation is used in inpatient and outpatient settings.
2. History and Physical (H&P):
An H&P is a detailed evaluation of the patient’s condition, including a comprehensive medical history and physical examination. It is used to diagnose and treat a patient’s condition. This type of documentation is used in inpatient and outpatient settings.
3. Operative Report:
An operative report is a record of a surgical procedure that includes relevant details such as patient information, preoperative diagnosis, postoperative diagnosis, anesthesia, surgical procedure details, and findings. It enables healthcare providers to track the patient’s progress throughout the surgical recovery process. This type of documentation is used in inpatient and outpatient surgery centers.
4. Discharge Summary:
A discharge summary is a record documenting the patient’s final diagnosis, treatment plan, and recommendations for post-discharge care. It includes a summary of the patient’s medical history, physical examination findings, laboratory results, and summary of all tests. This type of documentation is used in inpatient and outpatient settings.
Conclusion:
Understanding medical terminology and the different types of documentation in the HIM field is essential for medical college students and healthcare professionals. Through this assessment, students will demonstrate their proficiency in identifying misspelled medical terms, translating them into commonly-used terms, and analyzing the different types of documentation used in the HIM field.
