HIM FPX 4610 Capella Progress Note Help in Daily Monitoring of Patient Discussion
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.
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.
Part One: Operative Report
Carefully review the operative report for a patient who is having a sling replacement to treat urinary frequency and incontinence. Next, download the Operative Report Template [DOCX] and complete all of the following on the template:
Select 15 misspelled medical terms in the operative report and place them in Column 1.
Translate the 15 misspelled medical terms into commonly used terms in Column 2 correctly.
Place the correctly spelled medical term in Column 3.
Cite in correct APA style the references you used to perform your translation.
Preoperative Diagnosis: Urinary stress incontinence, cystocele.
Postoperative Diagnosis: Same.
History: This is a 49-year-old female with a history of a histerectomy and bilateral ophorectomy. She complains of urinarie frequency and incontinental. Options were discussed with patient, and she decided to proceed with a sling placement. Risks of the procedure were discussed. They include hemorhage, UTI, pielonephritis, cystitis, vaginitis, MI, DVT, PE, death, et cetera, and were deemed acceptable.
Operative Details: The patient was brought to the ER positioned, prepped and draped in the usual fashion. Time-out was called and patient identity and procedure being performed was validated. A Folley catheter was placed, and the bladder drained. Allis clamps were placed on the posterior vaginal muosa. A small incision was made, and the blader was lifted off of the vaginl mucosa. The cystcele was reduced. At this time, a minor enterocele was noted. Due to the small size, the interocele was not repaired. Bilateral stab incisions were made suprapublically and SPARC needs placed into the superpubic incisions and pulled through the vaginal incisions. The SPARC mesh was attached to the needles and pulled up through the insicions. The mesh was positioned against the mid-urethre, sutured into place, and cut below the surface of the sin. The skin was closed with 4-place suture; the vaginal incision was closed with 0-vicryl. The patient was transferred to the recovery room in stable condition.
Blood Loss: Minimal.
Part Two: HIM Terminology
Write a short, one-to-two-page paper on some of the types of documentation used in the HIM field. Be sure your paper includes all of the following headings:
History and Physical (H&P).
Under each heading, address each of the following:
Describe the purpose of the document.
Detail the contents included.
Identify settings where the document would be used.
Consult the Capella Writing Center as needed for additional writing resources to help your write the paper portion of your assessment.
Part One: Operative Report
Format: Ensure you complete all columns on the Operative Report Template.
Scoring Guide: Be sure to read the scoring guide for this assessment, so you understand how your faculty member will evaluate your work.
Part Two: HIM Terminology
Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
Title Page: You do not need to include a title page with your paper. You do need to label it HIM Terminology.
Name: Include your name in the upper right-hand corner on your paper.
Length: Approximately 1–2 typed and double-spaced content pages in Times New Roman, 12-point font, not including the reference page.
References: Include a minimum of one citation of peer-reviewed sources in APA format.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.