Jane Dares Record

The system was confusing at first, but once I started clicking around and exploring, it became easier to understand and locate the information I needed. I was able to find information like why the patient was there, vital signs, labs, allergies, past medical history, and medication schedule. After doing assessments I was able to document those findings and observations made during the assessments. For this task, I could improve by taking my time to chart and not chart findings vaguley. For my next clinical day, my goals for this task include taking my time while documenting, and to remember not to leave my patients information up on the screen if I walk

A sample of urine was taken from a patient with kidney disease was labeled as

Urethritis is a type of UTI which typically occurs when bacteria from the GI tract is

UTI’s (urinary tract infection) are an infection to the urinary system. There caused by certain bacteria

Department Organization: This 358 hospital bed acute care facility. The HIM department is staffed with twenty one individuals who hold various positions. There is one with a RHIA credential, and two with RHIT credential. The other members of the department include Certified Coding Specialists (4), Certified Coding Associates (1), Birth Recorders (1.5), Clerks (2.2), Technicians (6), System Technician (1), Registry (.8) and Document Specialists (2.2) with many tasks shared among the entire team. The information flow begins with the patient discharge. A new chart is created for each discharge. The chart is assembled, coded and then analyzed by senior HIM Specialist for deficiencies. If the chart is complete the chart goes to the main file. If not, complete MD is notified.

UTI is an infection of the urethra, bladder, ureters and kidneys that occurs when bacteria gain access to the urinary system (Dailly, 2011). This makes a patient's urine to contain bacteria during a laboratory test, and this bacteria is more prone to being active when

Urethritis is a swelling (inflammation) of the urethra. The urethra is the tube that drains urine from the bladder. It is important to get treatment for this condition early. Delayed treatment may lead to complications.

Pyelonephritis is a type of urinary tract infection that is caused by bacteria that affects one or both kidneys. The urinary tract involves the kidneys, ureters, bladder, and urethra near the middle of the back on both sides of the spine. This is the human body’s way of removing waste and excess water. Pyelonephritis is caused by bacteria and only affects the kidneys and Escherichia coli is often the bacterium that causes this infection. Men and women are both affected by this and are more likely to develop it by having diabetes, kidney stones, a bladder tumor or an untreated urinary tract infection. There are many symptoms to look for when you are experiencing the infection. Doctors can diagnose depending upon the age and gender of a patient.

Purpose: This lab will examine the difference between the different samples of urine that have either too much glucose or a strong acidic (pH) level, to determine the five types of disorders that each sample of urine might have.

Seeing how the results of each urine sample do not match the characteristics of healthy urine, it should be noted that all samples tested throughout the lab experiment each contain problems caused by diseases existing in the kidneys. To start, sample W comprises of one common scenario that indicates the presence of a kidney condition - that is the high concentrations of the macromolecule glucose that were found. When significant amounts of glucose are detected in urinalysis, it is most likely that the individual has a case of diabetes, notably type 1 and type 2. Complications arise when excessive amounts of glucose take up the liver. To illustrate, due to the large size of the glucose molecule, in comparison to other molecules that the kidneys filter, it harms the

employee/self-employed/student): Marital status (married/unmarried): Address: Patient’s Clinical profile: Chief complaints: Clinical Diagnosis: Past Illness: • Diabetes Mellitus: • Hypertension: • COPD: • Bronchial Asthma: • CAD: • CVA: • H/O Delirium: • Dementia: • Depression: Personal: • Alcohol intake:  Units of alcohol per day:  Frequency of intake:  Alcohol product used:  CAGE question score: • Smoking habit:  Product used for smoking:  No. per day:  Smoking index:

Interstitial cystitis is considered a chronic condition. It is not deemed an infection, although it might have the sensation of an infection to a patient (“What is Interstitial”, n.d.). It is commonly referred to as painful bladder syndrome. Many people who suffer from interstitial cystitis usually have other urinary related health issues such as “irritable bowel syndrome, fibromyalgia, and other pain syndromes” (“What is Interstitial”, n.d.).

Before the introduction of vaccines people were getting sick and ending up dying of unknown causes. Physicians and scientist started developing vaccines to stop some of the unknown illness that ware killing children and adults. One journal found that during the pre-vaccine era, most deaths occurring among young children ware related to diphtheria. Toxoids ware first introduced in 1920 in the U.S. They helped reduce incidents of respiratory diphtheria. This Toxoid is used to prevent diphtheria. Its purpose is to expose a small dose of the bacteria from the bacteria. Then the body develops immunity to the illness (“toxigenie,”1996). The pathogenesis of diphtheria involves two sub units called A and B. What happens is the toxin tries to

Katelyn, I agree that it is unacceptable to use unapproved abbreviations or ones that may be misunderstood or offend. Healthcare professional should be aware of all abbreviations, and if unsure of an abbreviation,

In this analysis the type of urine specimen used is random urine which is collected any time for routine analysis. A routine voided urine specimen requires no patient preparation and is collected by having the patient urinate into an appropriate container. Normally the patient requires no assistance other than clear instructions. For other collection procedures, the patient may require assistance depending on the patient’s age and physical condition or the technique to be used for collection. Routine urinalysis protocols typically require 10 to 15 mL of urine, but collection of a larger volume is encouraged to ensure sufficient urine for additional or repeat testing. (Bishop Michael L., 2010)