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Feb 20, 2024

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HCM 205 Final Project Template A Day in the Life of a Medical Scribe Section I: Documenting Patient Information Built Medical Terminology Phonetic Spelling 1 Pyelonephritis pai·uh·low·nuh·frai·tuhs 2 Dehydration dee·hai·dray·shn 3 Nephrolithiasis neh·frow·luh·thai·uh·suhs 4 Bacteremia /ˌbaktəˈrēmēə/ 5 Urogenital /ˌyo͝orōˈjenəd(ə)l/ 6 Afebrile ˌāˈfēbrīl/ 7 tympanic membrane tuhm·pa·nuhk mem·brayn 8 Erythema eh·ruh·thee·muh 9 Abscess ab·ses 10 Intravenous pyelography in-tra-ven-ous py-el-o-gram Place the recording of your pronunciation of the medical terms here: Section II: Reviewing Records for Accuracy

Incorrectly Spelled Medical Terms Accurate Spelling 1 Chief Complant Chief Complaint 2 Ilness Illness 3 Chess Chest 4 Wait Weight 5 Catheterisation Catheterization 6 Indijestion Indigestion 7 Nitroglycerine Nitroglycerin 8 Mycocardial infraction Myocardial infarction 9 Pane Pain 10 Treatmant Treatment 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. The SOAP note, in general, is written in a very unprofessional manner. The scribe seems to be extremely opinionated as opposed to being subjective and objective. Many of the inaccuracies lie within the misspellings of many of the terms. Time was not taken to ensure the proper spelling of the medical terms was written, which could potentially lead to confusion and possible misdiagnosis and subsequent treatments. The assessment section of the patient SOAP note does not interpret the findings of the objectives accurately. This is because all the vital signs of the patient were within normal ranges, but the assessment section of the SOAP note includes the hypertension, tachypnea, bradycardia and an unstable angina as the diagnosis. This is not accurate and very misleading because this information contradicts with the vital signs recorded on the objective section of the SOAP note. 2. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis: I would edit the patient's SOAP note, I'll look for typos and rewrite it appropriately. I will validate, after the spelling has been fixed, that there is a strong correlation between the information in the SOAP note's assessment area and the information in the subjective and objective sections.

Everything must be concise and accurate for other healthcare workers to use clinical reasoning to assess and treat the patient based on information provided by them. The patient's current condition must also be included in their symptoms. In order to get a good diagnosis and assessment I would make sure the objective and subjective were extremely accurate. I would check for misspellings, inaccurate information, proper use of the medical terms, and accurate diagnosis. Section III: Interpreting Patient Information Medical Terms Word Parts and Their Definitions Medical Term Definition Phonetic Spelling 1 Hypertension (HTN) hyper- excessive, above tens pressure A condition in which the force of blood flowing through the blood vessels is consistently too high; commonly called high blood pressure hī ˝ pĕr-tĕn´ shŭn 2 Bronchitis bronch bronchus -itis inflammation Inflammation of the bronchi. brŏng-kī´ tĭs 3 Orthopnea orth/o straight -pnea breathing Inability to breathe unless in an upright or straight position. or˝ thŏp´ nē-ă 4 Hemorrhoidectomy hemorrh vein liable to bleed -oid resemble -ectomy excision Surgical removal of hemorrhoids. hem″ŏ-roi-dek´to- me 5 Anti-inflammatory anti- against Inflammatory inflammation Preventing or reducing inflammation. ăn tē-ĭn-flăm ə-tôr ē, ăn tī- 6 Sinusitis sinus curve, hollow -itis inflammation Inflammation of the 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´ rē-ă

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9 Hematuria hemat blood -uria urine Presence of red blood cells (erythrocytes) in the urine. hē˝ mă-toor´ ē-ă 10 Nocturia noct night -uria Urine Urination during the night. nŏk-tū´ rē-ă 11 Arthritic arthr joint -itic pertaining to Relating to 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, emotion Enlargement of a gland. ad″ĕ-nop´ah-thee 15 Organomegaly organ/o organ -megaly enlargement, large Excess size of one or more organs. ȯr-gə-nō-ˈmeg-ə-lē Place the recording of your pronunciation of the medical terms here: Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record. Medical terms are built using prefixes, suffixes, root words, and combining forms. Prefixes are found at the beginning of a word, suffixes at the end. Prefix means to fix to the beginning of a word and changes the meaning of the word. Suffix means to fasten on and is used to make new words. Root words are what other words are created from and combining forms are the root words with vowels Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record. The official diagnosis is COPD – chronic obstructive pulmonary disease, which refers to a group of diseases that cause airflow blockage and breathing-related problems; asthma, which is a disease that affects your lungs. It will cause repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing; and acute bronchitis, which is essentially a “chest cold” and occurs when the airways of the lungs swell and produce mucus in the lungs, causing you to cough.

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