Instructions Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column‚ list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally‚ in the far right column‚ identify the source document. For example‚ face sheet‚ discharge summary‚ progress notes‚ or x-ray
Premium Hypertension Heart Myocardial infarction
The benefits using the abbreviations within a medical document is that Physicians spend a lot of their time with documentation. Abbreviations allow physicians to perform more work in less time. In other words‚ abbreviations will make your work flow a lot more efficient. However‚ the limitations out weigh the benefits. It can lead to confusion of what the writer is talking about or unsure of the abbreviation. The abbreviation could mean more than one thing and have to know what the
Premium Medicine Physician Nursing home
Jane Dare’s Health Record The pros of using a medical terms are easy to identify‚ now a days if you have taken the course to help you. Having a terms complete your reports for you it seem like it would have save you a great deal of time in the medical world. In the past‚ people probably dictated your reports for a transcription department just like almost every other physician did. However‚ with the advent of EHR‚ most systems have allowed hospitals to practically eliminate transcription altogether
Premium Medicine Health care Electronic health record
Painted Valley‚ USA Street Address Patient’s Name Dare‚ Jane V. Hospital Number 8032 Hao Jung Street Birth Date Age 10/31/xx City 73 Sex Phone Number San Francisco Marital Status F # 822999 823 762-3673 State Married Zip California Soc. Sec. # County 85321-9626 Calaveras 773 Race Religion 101-87-3546 Room Taoism Asian Ethnicity Patient’s Occupation Retired Non-Hispanic Notify In Emergency Name Relationship Jade Dare Responsible for Account Daughter Address Self
Premium Nursing home Home care Nursing
Define the following terms in the proper context for the chart of Jane Dare. Jane Dare Health Record Term Definition 1. CONGESTIVE HEART FAILURE Inability of the heart to keep up with the demands on it‚ with failure of the heart to pump blood with normal efficiency 2. LEFT PLEURAL EFFUSION Pleural effusion occurs when too much fluid collects in the pleural space. It is commonly known as “water on the lungs” 3. NONCONTRIBUTORY A pension plan in which participating members or employees are not required
Premium Hospital Physician Medicine
Name: Institution: Tutor: Date: Introduction Medical record numbering and filing is the most important tasks in the management of medical information in health care institutions. Well kept and filed medical records enhance effective and efficient collecting‚ recording and retrieval of patient health information whenever required. The patient record care system adopted influence the ease of maintenance and retrieval of medical records. According to the Remote Health Branch of United States
Premium Health care Medical record Number
Chapter 3 – Medical Record | History of Present Illness | Patient is a 35 year old male complaining of nausea‚ pyrosis‚ indigestion‚ and melena stool. Patient stated that he has been experiencing abdominal pain that wakes him in the middle of night for over a month. He stated that he normally can drink a glass of milk or baking soda water to relive the pain‚ but this has no longer been effective. | Past Medical History | Patient is a smoker who drinks daily and suffering from obesity.
Premium Myocardial infarction Hypertension
Chapter 3 – Medical Record History of Present Illness The patient is a 61 year old female. The patient is complaining that they feel weak‚ their urine is dark‚ nausea‚ pain in the abdomen. Past Medical History Mrs. Carter has suffered from seizures since she was 14 years old. She has been taking Dilantin to help keep her seizures under control and to a minimum. Clear history otherwise. Physical Examination Temperature was 99.8 Pulse was 83 Blood Pressure was 120/84 Abdomen area was swollen
Premium Medicine Medical history Pneumonia
for Diana Shannon’s M270 Electronic Heath Records and Medical Office Procedures course. With a world that is continually developing new technologies daily‚ the health care world is just one of many places trying to keep up with it. Manual records seem to be a thing of the past these days with more and more facilities switching over to electronic medical records. The few who are hesitant to take the plunge and convert over to electronic medical records may be thinking about the cost of the software
Premium Health care Medical history Electronic health record
Computer-based patient records is a system in which its function are becoming an essential technology for health care in part because the information management challenges were being faced by health care professionals that are increasing daily. The system stores data regarding additional medical information records in a relational database. Most published studies to date have been in the area of keeping the records safety. The database is a general setting of compiling not only the records of the patients
Premium Electronic medical record Medical record Microsoft Access