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 1–2 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.
Preoperative Diagnosis: Urinary stress incontinence, cystocele.
Postoperative Diagnosis: Same.
Anesthesia: General.
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, 1–2 page paper on some of the types of documentation used in the HIM field. Be sure your paper includes all of the following headings:
- Progress Note.
- History and Physical (H&P).
- Operative Report.
- Discharge Summary.
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.
