Benefits of Medical Abbreviations There are many benefits of medical abbreviations. One benefit of medical abbreviations is how much easier it makes it to read a chart. This speeds up the process by knowing the abbreviations and the use of them. It is nice to simplify things by using medical abbreviations when it is a busy day. The other reason to use medical abbreviations is so that only the medical personnel will know what is being described. It is a very efficient way of maintaining a patient’s privacy. Everybody does not need to know a patient’s medical history or what is going on with a patient or resident and allows their privacy to be protected.
Limitations of Medical Abbreviations There are often more than one meaning for an
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Even though the caregivers have her best interests at heart and are doing what they can to help, Jane believes they are the ones keeping her from going home. There were a few abbreviation mistakes that I noticed. There were no ICD-9-CM codes on the admission summary sheet. These codes are used for billing and the absence of these codes would cause her provider not to approve of her billing. The second mistake noticed was that all diagnosis were principle diagnosis and no secondary diagnosis. Which was the main reason for admitting Jane Dare, Congestive Heart Failure, left pleural effusion, or pneumonia? There should almost always be a secondary diagnosis with a primary. Another mistake noticed is the kind of antibiotic used when Jane was pit on an IV. Was there sulfa in it, considering Jane is allergic? Why was a blood culture not collected? If Jane was not able to sleep in her room because it is too hot or cold and the staff has found her sleeping on the floor, how do they know that she did not fall during the night? In RAP #8 it says that Jane needs the assistance of 1 to ambulate, however, the next statement reads that in a wheelchair she must be pushed to and from all locations because she gets SOB when doing it on her own. If she is able to ambulate, why is it she is having trouble in a wheelchair? Also, if psychotropic drugs are causing problems, why hasn’t the
• The accumulation of blood within the cranium, due either to head trauma or flaws in the cerebral vasculature
An experienced nurse Julie Thao was taking care of 16-yeas old Jasmine Gant who was about t give a birth. Thao is accused of making a mistake that had terrible and tragic result on the life of a pregnant teenage, unborn child, Gant’s family, health care, and Thao’s life. Thao mistakenly gave Gant an epidural anesthetic intravenously instead of an IV antibiotic for a strep infection. Within minutes of receiving the epidural IV, Gant suffered seizures and died. Her child, a boy, was delivered by emergency Caesarean section and survived. So what caused this tragedy to happen? According to investigation, Thao improperly removed the epidural bag from a locked storage system without authorization, she did not scan the bar code, which would have told
Jane had undergone several surgeries to her left leg due to crushing both her tibia, fibula as well as her broken ankle. Jane had also broken her femur on her left leg. Jane spent several weeks in the hospital recovering from her injuries. When she was stable enough, she was transferred to an inpatient rehabilitation facility in the hospital. Jane had spent about two weeks at that facility. During which her daughter had moved her dad in with her due to his needs. Jane was now even further away from her family. Jane had demonstrated good steady progress however, due to
1. The medical care facility should have had an interpreter there at the childbirth. I think it was absolutely ridiculous for Sherry to have to go through natural childbirth and have the incident with the air not being on as well. The doctors and nurses should have also been properly trained and more compassionate.
Medical terminology has a long and rich history that evolved in great measure from the Latin and Greek languages. “It is estimated that about three-fourths of our medical terminology is of Greek origin.”(Banay) “Latin accounts for the majority of root words in the English language.” (Fallon).
The nurse that originally noticed the shortage in anesthesia, in my opinion should have filed a formal compliant against the chief of anesthesia for not executing an investigation due to her speculation and evidence. If it was determined to be true that Dr. Johnson illegally using the anesthesia than he could have gotten some help. His illness could be in final stages not because he neglected to receive treatment. Instead of covering up the pain there is a possibility that he could have received treatments to help him through his illness. I think the employees of this hospital are at fault along with Dr. Johnson because they did not practice integrity and inform anyone of the incidents that they were noticing. Everyone gave excuses and the one that did say something should have complaint to someone who would have listened. A hospital mission is to care for their patients and the mission was not followed by any one who noticed Dr. Johnson’s actions.
The loss of control experienced by Ann may have had an impact on the time it took to progress through the stages. Involving Ann in the decision making, discussing options and offering continuity of care would help make the transition from her home environment easier.
There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The
Nursing assessment within 24 hours, Nutrition and hydration status, Functional status living, Social, spiritual, and cultural variables. Liza was admitted to the intensive care right away which wasn’t appropriate. The first step in the evaluation of a patient presenting with syncope consists of obtaining a detailed history and conducting a physical examination including blood pressure (BP) measurements and standard ECG. In this case, the nursing staff started began performing nervous system checks after 18 hours of her admission which is in my opinion was not appropriate because that should have been done right away after her arrival to the emergency room and after doing these evaluations, they should’ve decided on whether she was supposed to be admitted to intensive care or not. Also, the results of these tests would help them determine if a CT scan was needed and if needed, it should’ve been right away. In my opinion, Liza’s admission processes were not handled properly by the nursing staff at the hospital and her treatment was delayed. If all the processes were done on time and all the tests were done right away, her condition would not have worsened and she could have been started on anticoagulants for cerebral infarction. Patients have a better chance of survival and recovery if these drugs are taken within 12 hours of the incident. Most patients are administered these drugs within 90 minutes of hospital arrival.
Beneficence compounded by nurse-physician communication created ethical problems in this case. Mainly, Joanna’s assessment of Mrs. Kelly being ignored by the resident physician and the nursing supervisor. Joanna worked within the scope and standards of practice, she assessed, evaluated, and monitored her patient’s condition. She then reported her findings to the resident twice, and also sought nursing support from her shift supervisor. After Joanna’s first call to the resident, and her continued concern she needed to advocate in a proactive manner. Continuing her assessment of Mrs. Kelly to include palpation and auscultation could have offered additional clinical information enabling her to articulate the problem to the resident and nursing supervisor.
In my paper I will be discussing what medical terminology is, where it came from, and how it is applied to medical assistant careers as well as how it is applied to medical administration careers. I will give examples of the importance of medical terminology and specific examples of where medical careers use medical terminology on a day to day basis. I will also give a brief summary and definition of what medical terminology stands for. After reading my paper you should have a good concept of medical terminology’s importance, use, and why medical terminology is not just applied to medical assisting jobs but also why it is important for medical administration employees to also be familiar and have a good grasp on medical terminology.
Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report.
On august 13, 2016 I was assigned to follow one of the ICU Nurse. It was a very calm day. She had two patient one was more critical than the other. Both patients were on the ventilator because they had to be intubated the night before. The lady is obese and had gastric bypass surgery two years ago and suffering from severe sleep apnea, but the patient is non-compliance to the CPAP treatment. That was her second time being intubated. She was admitted for seizure monitoring because she was constantly having seizures the day before while she was at home. Due to the fact that she did not want to wear her CPAP machine while in the hospital, after pain medication was administered she was found unresponsive, that was the reason for her intubation the night before. Patient was on intermittent suctioning, she has sinus tachycardia . I had the opportunity to observe some of her daily care. The patient was on fentanyl but when the Dr. try to wean her out of the ventilator she stop breathing, therefore, the DR. discontinue the fentanyl temporarily in other to retest her later.
During the home health observation day, there were several opportunities to observe a variety of patients with varying levels of functioning ability, different illnesses, and different needs and levels of interaction with the nurse. The first patient seen was a seventy-three year old Caucasian female with an ulcer on her right heel. Several weeks prior, she had scratched her left leg and she also had several small wounds on her left leg. The orders were to clean and redress the ulcer. She has a history of end stage renal disease, pneumonia, weakness, diabetes, dialysis, and right hip fracture. Upon entering the home, the patient was found to be sitting in a wheel chair in the living room watching television with her husband close by her side. She greeted the nurse with a smile and began to update her on her current condition. Her heel was “hurting” and she rated her pain an 8 on a scale of 1 to 10. She also had some “swelling” that she could not “get to go away; because, she could not get up and walk. They need to fix my foot so that I can get up and get around.” She told the nurse that she had been to see the doctor “yesterday” and the doctor had given her a written order that she wanted her to see. The order was written for an evaluation for a soft pressure shoe fitting. The nurse read the order to
Besides the computer revolution, medical advances have caused tension between faith and reason. The medical advances of the Twentieth Century have many beneficial effects for humanity. Diseases that used to be dangerous or life threatening, like mumps, measles, and whooping cough, are no longer worries in todays medical world. Tetanus, typhoid, and the bubonic plaque can now be treated with antibiotics or other medicines. Vaccines, especially the polio vaccine, freed many people from the effects of a disease. Advances in heart surgery and organ transplants have saved many lives. Anesthetics and painkillers have been made to reduce or eliminate pain during surgery or a painful disease. Advances in cancer and AIDS have