HIM 4160 Assessment 4

Operative Report Template Numbe r Misspelled Medical Term Common Term Corrected Misspelled Word Exampl e 1 Uretr Tube connecting the kidneys and the bladder. Ureter 1. Histerectomy Hysterectomy Hysterectomy 2. urinarie urinary Urinary 3. incontinental incontinence Incontinence 4. hemorhage hemorrhage Hemorrhage 5. pielonephritis pyelonephritis Pyelonephritis 6. vaginitis vaginitis Vaginitis 7. interocele enterocyte Enterocyte 8. uprapublically suprapubically Suprapubically 9. superpubic suprapubic Suprapubic 10. insicions incisions Incisions 11. mid-urethre mid-urethra Mid-urethra 12. sin skin Skin 13. 4-place 4-0 suture 4-0 suture 14. muosa mucous membrane Mucosa 15. histerectomy hysterectomy Hysterectomy Part Two: HIM Terminology Organizing different kinds of documentation in hospital settings is known as health information management, or HIM (Barnes, 2020). In this section, we'll go over the goals, contents, and sets of essential HIM documentation types: Progress Note: Healthcare providers may communicate, coordinate, and make well-informed decisions with the support of progress notes, which act as real-time recordings of a patient's status and treatment progress. They include brief overviews of the patient's health and changes over time and include vital signs, thorough symptom descriptions, therapy updates, and physician 1

assessments. These adaptable records are essential in a variety of healthcare environments, guaranteeing thorough, coordinated treatment in clinics, hospitals, and long-term care homes (Jacob, 2020). A variety of healthcare settings, such as clinics, hospitals, and long-term care homes, use progress notes. Because of their adaptability, they are very helpful in tracking patients' development and promoting communication among the members of the care team. Progress notes guarantee that medical staff are knowledgeable and able to modify their methods in response to the patient's changing demands, whether in the hectic setting of an emergency department or throughout continuous care in a nursing home. They provide complete and coordinated treatment by serving as a record of a patient's medical journey. History and Physical (H&P): Essential parts of a patient's medical file, history and physical (H&P) records provide a thorough insight of the patient's past medical history and present state of health. Their main goal is to give medical practitioners a comprehensive picture, which will help with diagnosis and the creation of efficient treatment strategies (Swartz, 2020). Key components of H&P documentation include patient demographics, pertinent medical history, current complaints, thorough physical examination results, and tentative diagnosis. These records provide a crucial starting point for medical professionals to evaluate the patient's condition and direct further testing and treatment choices. Since H&P reports are most often used in acute care settings, hospitals, ERs, and surgical centers rely heavily on them. H&P records are essential to the early assessment and diagnosis of patients in these hectic settings, giving medical teams the knowledge they need to act quickly 2

minimize medical mistakes and care discontinuity by giving succinct summaries of a patient's status and advice for after discharge. Understanding the significance of discharge summaries in Health Information Management (HIM) is essential for preserving correct data, promoting provider communication, and guaranteeing ongoing patient care. References Barnes, S. J. (2020). Information management research and practice in the post-COVID-19 world. International Journal of Information Management , 55 , 102175. https://doi.org/10.1016/j.ijinfomgt.2020.102175 Jacob, P. D. (2020). Management of patient healthcare information: Healthcare-related information flow, access, and availability. In Fundamentals of telemedicine and telehealth (pp. 35-57). Academic Press. https://doi.org/10.1016/B978-0-12-814309- 4.00003-3 4

Jin, Y. H., Zhan, Q. Y., Peng, Z. Y., Ren, X. Q., Yin, X. T., Cai, L., ... & Chinese Research Hospital Association (CRHA). (2020). Chemoprophylaxis, diagnosis, treatments, and discharge management of COVID-19: An evidence-based clinical practice guideline (updated version). Military Medical Research , 7 , 1-33. https://link.springer.com/article/10.1186/s40779-020-00270-8 Swartz, M. H. (2020). Textbook of physical diagnosis E-book: history and examination . Elsevier Health Sciences. https://books.google.co.ke/books?hl=en& Zhou, L. L., Owusu-Marfo, J., Asante Antwi, H., Antwi, M. O., Kachie, A. D. T., & Ampon- Wireko, S. (2019). Assessment of the social influence and facilitating conditions that support nurses’ adoption of hospital electronic information management systems (HEIMS) in Ghana using the unified theory of acceptance and use of technology (UTAUT) model. BMC medical informatics and decision making , 19 (1), 1-9. https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-019-0956-z 5