Progress Note Help in Daily Monitoring of Patient

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Progress Note Help in Daily Monitoring of Patient essay assignment

Question Description
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.

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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.

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