patients for medical histories and chief complaints, measure vital signs, and review medication lists -Accompany MD in exam room to document exam findings, diagnoses, and treatment plans -Perform spirometry and EKGs, process labs, & prep and assist with venipunctures, urinalysis, injections, and cosmetic procedures (i.e. Coolsculpting, Botox, etc.) -MedSpa duties include marking treatment areas, applying topical anesthetic/gel, adjusting procedural settings, and explaining post-treatment care -Instruct
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. Abbreviation Letters Represent Context Definition or Application within the Patient’s Chart Source Document 1. ICD International classification of disease As it pertains to Jane Dare’s disease Admission Summary 2. CM
Answer the Following Questions: 1. The transfer of tissue or an organ between two people who are not related is called? ANSWER: Allotransplantation 2. How would aspiration of urine from the bladder be accomplished? ANSWER: By means of needle, trocar, or ultracatheter 3. A collection of structures that suspends the testes in the scrotum is called? ANSWER: Spermatic Cord 4. What is it called when an egg from the female is withdrawn and fertilized with sperm in a laboratory for 2 to 3 days
American Male who presents to Daybreak Clinic on September 2, 2015 for his routine follow-up exam for his hypertension, gout, and chronic back pain. His labs were collected Monday, August 31 and will be reviewed today. He reports that he has been out of his medications for a week due to needing a refill. He has a refill available that he reports he was unaware of. This will be his last visit to Daybreak due to his Social Security and Disability approvals. In addition to his medical needs today
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After the patient has arrived, the primary nurse on duty receives a report from the Emergency Medical Technician (EMT) that accompanied and provided initial care to the patient in the ambulance. At the same time, the secondary nurse and ERT become technical, or hands on. The patient is administered oxygen, cardiac monitors are placed, an EKG is administered, locks and labs are drawn, normal saline is administered, and a urinalysis is taken along with the patients’ blood glucose level. Each of these
Student Name: Dealon Rouse | Patient Initials: JB | Admission Diagnosis: Left Total Knee Arthroplasty &Excision of Left Knee Mass Related to Gouty Arthritis | Date(s) of Care: 11/10/11- 11/12/11 | Age: 46 | | Date of Admission: 11/10/11 | Gender: Male | | Marital Status: Married | Room #: 507 | Code Status: Full Code | Occupation: Electrician | Race: Hispanic | Isolation Type: | Religion: Roman Catholic | | Allergies: No Known Allergies | History of Present Illness:
Gender: Female (Accompanied by Daughter) Chief complaint: Altered Mental Status, Anorexia History of Present Illness: Onset: female (Black) patient reports symptoms of fever (102.4 in a.m.) with decreased appetite with onset of symptoms, urinary frequency, urgency, dysuria and nausea. The family also reports that for the last two days the patient has been increasingly confused, and does not recognize family. Past Health History: Patient is current on all childhood vaccinations
person is there to observe the employee to ensure there is no specimen tampering including turning the water valve off for the toilet. The lab procedure is a second invasion of privacy. Urinalysis reveals not only the presence of illegal drugs, but also the existence of many other physical and medical conditions – or pregnancy. How about human error in the lab, or the test's failure to distinguish between legal and illegal substances, can make even a small margin of error add up to a huge potential
R.H. has a large, active family in the area who assist in his care and plan of treatment as much as possible, and provide daily visits. Prior to the most recent hospital admission, the family reports he was an active man who lived alone, and was quite capable of caring for himself and his house. He has a wife who suffers from dementia and is cared for by their children. He meets with his primary care doctor as well as a home health nurse frequently