Medical Abbreviations Essay

• The accumulation of blood within the cranium, due either to head trauma or flaws in the cerebral vasculature

For the verbal orders and read backs graph needs to be broken down into quarters. This would help address the problems sooner for the next fiscal year. During a department’s grand rounds, it needs to be reiterate the important of verbal orders and read backs are to patients’ safety. The smaller sample size may point to an individual doctor or nurse who needs retraining. This will help with orthopedics department improvement at fast rate and take other department to one hundred percent. The rush of the orders being given may lead to the using of impropriate use of abbreviations. The U abbreviation needs to be address in grand rounds of each department. The reporting of critical results need to address with laboratory staff and nurses, The doctors should be warned that when order something, “stat” to ask for the results within a reasonable amount of time. This will help in patient’s safety because it saves of life.

Assign a report all the coders and dates that are clearly and consistently support by the health record.

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

Present the “Doctor’s Notes” portion of the case with a description or definition of the following terms or concepts:

General: no history of weight change, fever or chills, weakness, fatigue, or change in appetite;

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing

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.

Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness

Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)

As a result of the introduction of computer technology and the combination of evidence-based practice in nursing; standardization of terminologies has become imperative in the classification of nursing diagnosis, interventions and expected outcomes. The most popular and successful systems are the North American Nursing Diagnosis Association International (NANDA-I), Nursing Outcomes Classification (NOC), and Nursing Intervention Classification (NIC) (de Lima Lopes, de Barros, & Marlene Michel, 2009). This paper aims to provide a brief outline of these standardized terminologies (STs) as they relate to a

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

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