W6A.1. Lab Assignment #2. Using the sample medical record, identify medical terms outlined in the diagnosis and procedure section, discharge summary and history and physical report. For each term, create a flash card table to 1) identify the term 2) provide a definition, and 3) document the prefix and suffix. Flash Card Table Medical Term Definition Prefix. I added the link to view the sample medical record and I’ve added the Flash Card Table. Suffix https://edge.apus.edu/access/content/group/health-sciences-common/Program/HealthInformationManagement/HIMA/HIMA400/HIMA400%20sample%20record2.pdf Flash Card Table Medical Term Definition Prefix Suffix
The parents of a 2 month old infant often took him along with them on their frequent trips to the mall. One of the grandmothers suggested that they leave him home as it was flu season and the malls were full of coughing and sneezing people. The mother immediately responded that she was breast feeding the baby and with all the antibodies from her he was surely protected against any diseases in the mall. Later as she sat at the pediatrician’s office, holding her sick baby, she expressed disbelief that he could have caught the flu. If you were the […]
Operative Report, Colon Polypectomy Report the services for the following case. When reporting the diagnosis for the operative procedure, reference the pathology report located in 7-8B. LOCATION: Outpatient, Hospital PATIENT: Jatin Al-Assad SURGEON: Larry Friendly, MD SCOPE USED: Pentax video colonoscope MEDICATIONS GIVEN: Fentanyl 75 mg (microgram) and Versed 3 mg (milligram) IV (intravenous) prior to the procedure PREOPERATIVE DIAGNOSIS: Polyp on sigmoidoscopy POSTOPERATIVE DIAGNOSIS: Colon polyps PROCEDURE PERFORMED: Colonoscopy with removal of polyps INDICATION: The patient is a 48-year-old male who presented for screening sigmoidoscopy on January 15. He was found to have several adenomatous polyps in the sigmoid […]
W6A.1. Lab Assignment #2. Using the sample medical record, identify medical terms outlined in the diagnosis and procedure section, discharge summary and history and physical report. For each term, create a flashcard table to 1) identify the term 2) provide a definition, and 3) document the prefix and suffix. I’ve attached the sample medical record because I would need to be logged in in order for you see it. Flash Card Flash Card Table Medical Term Definition Prefix Suffix Table Medical Term Definition Prefix Suffix SIMON, MYRNA IPCase004 Dr. BLACK Admission: 09/11/YYYY DOB: 02/08/YYYY ROOM: 0365 I, Myrna Simon hereby […]
1. What are the implications for nursing education as the EHR becomes the standard for caring for patients? 2. What are asked about a diagnosis with which you are unfamiliar. Where would you start looking for information? How would you determine the validity of the information?