SNHU MT Final Project PDF

Preview

Summary

Final project for the class....

Description

HCM 205 Final Project Template A Day in the Life of a Medical Scribe Complete this template using Patient Record One, Patient Record Two, and Patient Record Three. Then, submit the completed template to your instructor for grading. Be sure to include files of your recordings of the pronunciation of medical terms, using a tool such as Vocaroo. You can paste the links or files directly in this document. For support using Vocaroo, refer to the Vocaroo Tutorial document. Section I: Documenting Patient Information Complete the table below by building medical terms that correspond with the numbered phrases in the Progress Notes section of Patient Record One. Be sure to use the appropriate word parts to build the terms. Also include the phonetic spelling for each term in the table. Built Medical Terminology

Phonetic Spelling

1

Pyelonephritis

pī-(ə -)lō-ni-ˈfrī-t əs

2

Dehydration

dē-ˌ hī-ˈdrā-sh ən

3

Nephrolithiasis

nef-rō-li-ˈthī-ə-səs

4

Sericulture

ˈ ser-ə -ˌkəl-chər

5

Genitourinary Infection

ˌ je-nə -tō-ˈ yu2r-ə-ˌner-ē

6

Afebrile

(ˌ )ā-ˈ fe-ˌ brī(-ə)l

7

Tympanic Membrane

tim-ˈ pa-nik ˈmem-ˌbrān

8

Integumentary

in-ˌ te-gyə -ˈ men-t(ə-)rē

9

Abscess

ˈ ab-ˌses

10

Intravenous Pyelography (IVP)

Place the recording of your pronunciation of the medical terms here: https://voca.ro/162ymBQPBZ7S

ˌ in-trə -ˈ vē-nə s ˌ pī-ə-ˈläg-r ə-fē

Section II: Reviewing Records for Accuracy Complete the table below by listing the incorrectly spelled medical terms from Patient Record Two, and provide the accurate spelling. Incorrectly Spelled Medical Terms

Accurate Spelling

1

“complant”

Complaint

2

“mycocardial infraction”

Myocardial Infarction

3

“catheterisation”

Catheterization

4

“indijestion”

Indigestion

5

“chest pane”

Chest Pain

6

“treatmant”

Treatment

7

“chess discomfort”

Chest discomfort

8

“gained a fair amount of wait”

Weight

9

“lflush”

Flush

10

“ilness”

Illness

Review the subjective, objective, assessment, and plan (SOAP) note in Patient Record Two to ensure the interpretation of the notes is accurate, based on the patient’s diagnosis and results of relevant vitals. To complete this review, address the following: 1. Identify inaccuracies of interpretation in the SOAP note and explain why these elements are inaccurate. In the subjective section, “Chief Complant” is misspelled, along with other several grammatical errors as listed above. Additionally, it is stated that the patient was preparing his breakfast in the restroom which surely has to be a typo. The note also makes it seem as though the patient’s wife was present during this visit, making statements such as, “According to his wife, he has been having more frequent episodes”. However, it looks like his pastor was the one who was accompanying the patient and not his wife. The information pertaining to the patient’s past medical history, such as having a myocardial infarction and catheterization, should have probably been placed in the “Past Medical History” section rather than “History of Present Illness”. Now, the “Review of Systems” states results were negative, however, when the patient was assessed, it looks like tachypnea, bradycardia, and hypertension were detected. This actually contradicts the numbers listed under the vital signs, which claims everything was within normal range. 2. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis: When reviewing a SOAP note, I think first and foremost one of the most important things to do is review for grammatical errors. While I understand that an error or two may happen, the number of errors in this note were far too many. Additionally, the mentioning of the patient and how he “probably should be running some sort of hardware store commercial” was not necessary. Providers often mention how pleasant a patient is and I think that is completely okay but anything after that is unnecessary. Before finalizing the note, verifying that everything “matches” is important. As mentioned, it was stated the patient’s vital signs were all within normal range but the assessment indicated otherwise. This can be extremely dangerous in the sense that a patient may not receive the care they need or treatment they DON’T need.

Section III: Interpreting Patient Information Complete the table below by first listing the key medical terms from the History and Physical Exam section of Patient Record Three that would need to be defined for the patient. Then, break each term into its word parts, and define each word part. Next, provide definition for the medical term as a whole. Finally, provide the phonetic spelling of the medical term. Medical Terms 1

Hypertension (HTN)

Word Parts and Their Definitions Prefix: hyper – excessive Root: tens – above, pressure

Medical Term Definition High blood pressure (HBP) is defined as elevated systolic pressure above 130 or

Phonetic Spelling ˌ hī-pə r-ˈten(t)-sh ən

Suffix: -ion – process

diastolic pressure above 80 with at least two readings on separate office visits.

Root: bronch – bronchus Suffix: -itis – inflammation

Inflammation of the bronchioles.

Orthopnea

Combining: orth/o – straight Suffix: -pnea – breathing

Inability to breathe unless in an upright or straight position.

Hemorrhoidectomy

Combining: hemorrh – vein liable to bleed Suffix: -oid – resemble; -ectomy – surgical excision

Surgical procedure to remove hemorrhoids ˌ an-tē-in-ˈfla-m ə-ˌto2r-ē

Anti-inflammatory

Prefix: anti – against

Anti-inflammatory is the property of a substance or treatment that reduces inflammation or swelling.

Sinusitis

Root: sinus Suffix: -itis - inflammation

Inflammation or swelling of the tissue lining the sinuses.

ˌ sīn-yə-ˈsī-t əs

Diarrhea

Prefix: dia – through flow Suffix: -rrhea

Frequent passage of unformed watery stool.

ˌ dī-ə-ˈrē-ə

Dysuria

Prefix: dys – difficult Suffix: -uria – painful urine

Difficult or painful urination.

Hematuria

Root: hemat – blood Suffix: -uria – urine

Presence of red blood cells (erythrocytes) in the urine.

Nocturia

Prefix: noct – night Suffix: -uria – urine

Urination during the night.

2 Bronchitis 3

4

5

6

7

8

9

10

11 Arthritic

Prefix: arthr – joint Suffix: -itic – pertaining to or relating to

brän-ˈkī-təs

ˌ o2r-ˌthäp-ˈnē- ə

ˌhem-ə-ˌ ro2i-ˈdek-tə-mē

dis-ˈyu2r-ē-ə

ˌ hē-mə -ˈ tu2r-ē-ə

näk-ˈ t(y)u2r-ē-ə

är-ˈthri-tik Pertaining to or relating to arthritis.

12 Ecchymosis

13

Rhinorrhea

Prefix: ec – out Root: chym – juice Suffix: -osis – condition Combining: rhin/o – nose Suffix: -rrhea – flow, discharge

14 Adenopathy

15 Organomegaly

Combining: aden/o – gland Suffix: pathy – disease

Abnormal condition in which the blood seeps into the skin causing discolorations ranging from blue-black to greenish yellow; bruise.

ˌ e-ki-ˈ mō-səs

ˌ rī-nə-ˈ rē-ə Discharge from the nose. Immune system glands that usually enlarge in response to a bacterial or viral infection.

ˌ ad-ᵊ n-ˈäp-ə-thē

ˌ o2r-gə -nō-ˈmeg-ə-lē

Prefix: organ – organ Suffix: megaly – enlargement Enlargement of an organ.

Place the recording of your pronunciation of the medical terms here: https://voca.ro/1i4ZSNq6uwVw Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record. The guidelines for building medical terms consist of the use of a prefix, suffix, and/or root or combining form. The prefix is always placed at the beginning of the word, the suffix is always at the end, and root/combining form is the foundation of the word. The prefix often identifies a subdivision or part of the central meaning, the suffix modifies the central meaning as to what or who is interacting with it or what happens to it, and the root/combining form is often the central meaning. For example, myocarditis: “myo” means muscle, “card” is heart, and “it is” means inflammation. Myocarditis is the inflammation of the middle layer of the heart wall. If you change the prefix to “peri”, you now have “Pericarditis” which is the swelling and irritation of the thin saclike membrane surrounding the heart.

Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record. A 55-year-old gentleman presented himself on 04/26/YYYY with severe COPD, asthma, and hypertension. At the time of admission, patient indicated he had been experiencing shortness of breath for the past 24 hours, negatively impacting his ability to walk. A week ago, patient developed acute bronchitis and was prescribed 500 mg of Ampicillin....