8-1 Final Project: Medical Scribe Portfolio

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8-1 Final Project: Medical Scribe Portfolio

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8-1 Final Project: Medical Scribe Portfolio
The final project for this course is a medical scribe portfolio in which you assume the ro…View more

University
Southern New Hampshire University
Course
Medical Terminology (HCM205)
Academic year
2021/2022

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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 ̋ ĕ-lō-nĕ-frī ́ tĭs

2 dehydration dē-hī ́ drā zhŭn

3 nephrolithiasis nĕf ̋ rō-lĭth-ī ́ ă-sĭs

4 septicemia sĕp ̋ tĭ-sē ́ mĭ-ă

5 genitourinary jĕn-ĭ-tō-ū r ́ĭ-ner ̋ē

6 afebrile ă-fĕb rĭl′

7 tympanic membrane tĭm-păn ́ ĭk mem- brān

8 erythema ĕr ̋ ĭ-thē ́ mă

9 abscess ăb ́ sĕs

10 intravenous pyelogram ĭn ̋ tră-vē ́ nŭs pī ́ ĕ-lō-grăm

Place the recording of your pronunciation of the medical terms here: voca/1grICO0BLNnZ 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 mycocardial infraction myocardial infarction

2 catheterisation catheterization

3 indijestion indigestion

4 ilness illness

5 chess discomfort chest discomfort

6 Nitoglycerine Nitroglycerin

7 chest pane chest pain

8 treatmant treatment

9 wait weight

10 Chief Complant Chief Complaint

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. Initially, there are several spelling errors in the SOAP note which could ultimately lead to improper care for the patient and cause confusion among the medical staff. The assessment states hypertension, which is a blood pressure above 140/90, although vitals in the objective section state a normal blood pressure of 118/78. Assessment also states tachypnea, abnormally rapid breathing, although vitals state normal respirations at 18 with chest symmetrical and clear to auscultation and percussion. Lastly assessment states bradycardia, slower than normal heart rate, although vitals state a normal pulse of 65 and regular heart rhythm without any particular murmurs or gallops.

the anorectum -ectomy surgical excision, surgical removal, resection

5

Anti-inflammatory

anti- against inflammatory inflammation

A drug or substance that relieves swelling, tenderness, redness, and pain of inflammation

ăn ̋ tĭ-ĭn-flăm ́ ă-tŏr ̋ ē
6

Sinusitis

sinus a curve, hollow -itis inflammation

Inflammation of a sinus sī ̋ nŭs-ī ́ tĭs
7

Diarrhea

dia- through -rrhea flow

Frequent passage of unformed watery stool dī-ă-rē ́ ă
8

Dysuria

dys- difficult, painful -uria urine

difficult or painful urination dĭs-ū ́ rĭ-ă

9 Hematuria hemat blood -uria urine

presence of red blood cells in the urine hē ̋ mă-tū ́ rĭ-ă
10

Nocturia

noct night -uria urine

urination during the night nŏk-tū ́ rĭ-ă

11 Arthritic arthro joint -itic pertaining to

Pertaining to arthritis; A person afflicted with arthritis

ar-thrit ́ik
12

Ecchymosis

ec- out chym juice -osis condition

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

ĕk-ĭ-mō ́ sĭs
13

Rhinorrhea

rhin/o nose -rrhea flow, discharge

Discharge from the nose rī ̋ nō-rē ́ ă

14 Adenopathy aden/o gland -pathy disease

any abnormal enlargement of a lymph node as a result of infection or metastatic cancer

ad-ĕn-op ́ă-thē

15 Organomegaly organ/o organ -megaly enlargement, large

the enlargement of internal organs or ̋gă -nō-meg ́ă-lē

Place the recording of your pronunciation of the medical terms here: voca/1fTiY5O8oEl

1. Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record. When building medical terms, identify the root word because it is the foundation of the word. When more than one root word is used, it is a compound word which requires the use of a combining vowel to separate the words. Then identify if the word has a prefix, which is placed at the beginning of the word, and a suffix, which is placed at eh end of the word. Now when defining the medical terms, begin with the suffix and read backwards. If the word also contains a prefix, define the suffix first, prefix second, and root word(s) last. For example:
2. Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record. You have hypertension (high blood pressure) and asthma (inflammation of the airways causing airflow in and out of the lungs to be restricted) with acute bronchitis (viral infection causing inflammation of bronchial tubes) and bronchospasm (tightening of bronchial muscles causing narrowing airways).
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3. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s
   diagnosis: When revising, I would start by correcting the misspelled words then making sure the information stated in the
   assessment section reflected the information that was collected and stated in the objective section of the SOAP
   documentation.
   Below is the answer I was looking for
4. The diagnosis of bradycardia should be removed, as the pulse is 65, which is normal.
5. The diagnosis of tachypnea should be removed, as respirations are 18, which is normal.
6. The diagnosis of hypertension should be removed, as the blood pressure is 118/78, which is normal.
   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 Word Parts and Their Definitions Medical Term Definition Phonetic Spelling
   1
   Hypertension (HTN)
   hyper- excessive, above
   tens pressure
   -ion process
   High Blood Pressure. Also canned the “silent
   killer.” Elevated systolic pressure above 130 or
   diastolic pressure above 80 with at least two
   readings on separate office visits.
   h& ‘ p(r-t(n + sh0n
   2Bronchitis bronch bronchus
   -itis inflammation
   Inflammation of the bronchi brRng-k& + ,s
   3Orthopnea orth/o straight
   -pnea breathing
   Inability to breathe unless in an upright or
   straight position
   or ‘ thRp + n–2)
   4Hemorrhoidectomy hemorrhoid Mass of dilated,
   tortuous veins in
   surgical removal of hemorrhoid h(m + -royd (k + tR-m- the anorectum -ectomy surgical excision, surgical removal, resection 5 Anti-inflammatory anti- against inflammatory inflammation A drug or substance that relieves swelling, tenderness, redness, and pain of inflammation 2n ‘ ,-1n-fl2m + 2-tRr ‘ – 6Sinusitis sinus a curve, hollow -itis inflammation Inflammation of a sinus s& ‘ n0s-& + ,s 7Diarrhea dia- through -rrhea flow Frequent passage of unformed watery stool d&-2-r- + 2 8Dysuria dys- difficult, painful -uria urine difficult or painful urination d1s-ū + r1-2 9Hematuria hemat blood -uria urine presence of red blood cells in the urine h- ‘ m2-tū + r1-2 10 Nocturia noct night -uria urine urination during the night nRk-tū + r1-2 11 Arthritic arthro joint -itic pertaining to Pertaining to arthritis; A person afflicted with arthritis ar-thrit´ik 12 Ecchymosis ec- out chym juice -osis condition Abnormal condition in which the blood seeps into the skin causing discolorations ranging from blue-black to greenish yellow; bruise (k-1-m + s1s
   13 Rhinorrhea rhin/o nose
   -rrhea flow, discharge
   Discharge from the nose r& ‘ n*-r- + 2
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8-1 Final Project: Medical Scribe Portfolio