Health Care Record in Doctors’ Offices and Hospitals
Translate into common terms the medical terms contained in a progress note for a patient with a skin condition. Spell all medical and common terms correctly on the provided template.
In this first assessment you will begin your exploration of the structure of medical terminology. The first step is to review how to build a medical term. Then you will examine the skin and musculoskeletal systems; in particular, we will focus on the diagnosis and treatment of the integumentary, or skin system. The skin is the largest organ of the body with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold. Your suggested resources address the three layers of skin, skin conditions, diseases, treatment, and diagnostic studies. Health Care Record in Doctors’ Offices and Hospitals
In the assessment, you will review a progress note. This is a common document found in a health care record in doctors’ offices and hospitals. You will then translate the medical terms in the progress note into common terms.
Demonstration of ProficiencyBy 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 6: Spell and pronounce basic medical terms.Spell medical and common terms correctly.
Competency 7: Communicate in a professional manner.Provide citations and references in APA style. InstructionsReview the progress note below, including the subjective and objective notations. Next, download the Skin Progress Note Template [DOCX] and complete all of the following on the template:
Select 15 medical terms from the progress note. Health Care Record in Doctors’ Offices and Hospitals
Translate the 15 selected medical terms into commonly used terms. Spell the 15 medical and common terms correctly.
Cite in correct APA style the references you used to perform your translation. Click APA Style and Format for additional guidance on how to ensure your citations and references conform to APA guidelines.
Skin Progress NoteSubjective: The patient is a 49-year-old female who comes in with the complaint of having bumps on her arms. She states some of the bumps have been there a long time. Recently the bumps have been increasing in number and size. She was last seen about two years ago for eczema, at which time she did not have these bumps. The bumps are not itchy or painful.
Objective: Very pleasant, alert, and oriented x3 female in no apparent distress. A full integumentary exam of the upper extremities was performed today. The left radial aspect demonstrated erythematous macules. The right ulnar aspect demonstrated actinic keratosis. Bilateral hands appeared dry with linear excoriation and fissuring of her fingertips. Bilateral upper arms demonstrated superficial and deep masses. Deep subcutaneous masses are mobile and may represent lipomas. Superficial masses appear to be sebaceous cysts. Health Care Record in Doctors’ Offices and Hospitals
Assessment and Plan:
Actinic keratosis of the right ulnar aspect was treated with liquid nitrogen.
Possible lipomas: Schedule surgical biopsy of larger masses.
Sebaceous cysts: Punch biopsy performed today; await pathology report. Apply Neosporin to biopsy site.
Continue Cortisone 10 intensive cream for eczema.
Additional Requirements Format: Ensure you complete all columns on the Skin Progress Note Template. Scoring Guide: Be sure to read the scoring guide for this assessment, so you understand how your faculty member will evaluate your work. Health Care Record in Doctors’ Offices and Hospitals