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Medical terminology 2
Medical terminology fundamental
Medical terminology 2
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To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
As nurses, we've all had to deal with physicians and others who have really bad handwriting. In a clinical situation, the nurse can speak with the physician to ask for clarification of, say, orders that are illegible. It's not as easy once a lawsuit is being contemplated or has been filed. In-house and independent LNCs may not be able to informally clarify records with treaters depending on the circumstances of the case and whether the LNCs are working for the plaintiff or defense. To maintain their objectivity, expert LNCs never speak with non-client treaters.
Deciphering horrible handwriting from medical records is a skill that many legal nurse consultants learn through trial and error. This discussion focuses on physician handwriting but the principles apply to other types of health care providers as well. Here are some tips to help new LNCs who are trying to figure out illegible handwriting.
Use your judgment deciding how much time to spend deciphering bad handwriting. All medical records are important but some are more so than others. For example, it may not be ...
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...iter's notes in one sitting. Sometimes you'll be able to read words in a later note which will enable you to understand earlier notes.
Conversely,it may help to let the task of deciphering sit for a day or two if possible. Sometimes words that eluded you earlier will pop out at you after a few days.
Use the process of "fresh eyes." If you have access to another legal nurse consultant, ask her or him to view the problematic handwriting and give you suggestions.
Even using these principles, there may still be some illegible documents or portions of documents that you will be unable to interpret. When this occurs, tell the attorney about the indecipherable notes and the potential significance of the notes. The attorney can then decide to depose the treater or get a transcript of the treater's notes, depending on the circumstances and specifics of the case.
During the 1980’s and 90’s there were many studies done that showed that medical errors were occurring in inpatient and outpatient settings at a very high rate. Computer Provider Order Entry (CPOE) systems were designed to reduce or eliminate mistakes made by using hand written orders. The CPOE system allows users to directly enter their orders into the system on computers which are then sent directly to the healthcare providers that will be implementing the orders. Previously orders were placed by writing on order sheets on patient charts. This was sometimes done by the doctor or by a nurse acting on behalf of the doctor. Order sheets were then signed by the doctor and then the information was input into the patient’s record. This left room for error due to misreading bad handwriting, confusing medications with similar names, etc.
Mrs. Ard brought a wrongful death law suit against the hospital (Pozgar, 2014). The original verdict found in favor of Mrs. Ard, but the hospital appealed the court’s ruling (Pozgar, 2014). During the course of the appeal, an investigation of the records showed no documentation, by a nurse; of a visit to Mr. Ard during the time that Mrs. Ard stated she attempted to contact a nurse (Pozgar, 2014). The nurse on duty stated that she did check on Mr. Ard during that time; however, there were no notes in the patient’s chart to backup the claim that Mr. Ard had been checked on (Pozgar, 2014). One expert in nursing, Ms. Krebs, agreed that there was a failure in the treatment of Mr. Ard by the nurse on duty (Pozgar, 2014). ...
Communication between the general practitioners initiate from both DHB and nursing home is key to acquire accurate medical history (Huntington, Kuhn, 2003), then nurse of the DHB and the nursing home will do a hand over to also provide accurate information on medication and medical history. Admin personnel will undergo same procedure to endorse legal paper work and the patient’s chart to carry over to the nursing home for continuous care. Communication and endorsements then continues from both sides as this is important to avoid any medical error in the future (Huntington, Kuhn,
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
An essential part of a neurosurgeon’s role is to correctly handle the documentation of data pertaining to their patients' treatment. This specific data records contains treatment programs and schedules, medication plans, diagnosis details and any other analysis information pertaining to their patient’s health.
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
...ting legibly is the biggest concern. Having legible writing makes the whole operation of the radiology unit flow together. If the writing isn’t legible then it could cause the whole process to stop. Having the process stop isn’t good. It causes the process to be slower and risking peoples lives. For example, the x-rays can show blood flow. Having a very quick process could save someone’s life if they were bleeding out and needed a fast x-ray of where the bleeding was coming from and how it could be stopped. Having the writing be very clear and legible lives can be saved and make he process easy for the technician, radiologist, and physician.
chartings in the medical record of a patient, taking the patients vitals and reporting abnormal to
It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected.. The purpose of a medical record is for the health care provider to provide care to the individual patient.
...eat thing when they are used properly, but it is very important that the person using them knows when they should and should not be used. There are things that can be done to try reducing risks that are associated with the misuse of abbreviations. Although Eliminating all medical abbreviations would definitely help get rid of all the problems that follow, it does not have to be the only choice in the matter of reducing the risks. Making sure that all health care personnel follow the written policies that are in place is a very important part of working in the medical field. Accreditation agencies are now starting to compose lists of all the abbreviated terms that should not be used any more. Finally, abbreviations are an important part of any medical professional's life, but when it comes to handwritten documents it is often more of a nuisance rather then a blessing.
There are many documents that will be used as a pediatric nurse such as growth charts, percentile charts, patient charts, physician notes, follow up letters, and infant basic care information packets. All the documents no matter how small they may seem are an important part of the patients
For instance if a patient refuse to take his medication nurses document exactly what the patient said in the patient’s own word like nurse I won’t take this drug am tired of it and he threw it on the floor. The nurse in question will document the time, date and her full name including signature to avoid being criticized she will go further to explain how she notified the physician, how she provided the care and also verbal and non-verbal responses of the patient .
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
I will compare the Terminal-Digit and Alphabetic filing systems. The Terminal-Digit system requires slightly more training than the Alphabetic system but offers more security. The Alphabetic system compromises security because patient names are displayed on the outside of the record, which makes patient-specific information easier to locate for unauthorized persons; the Terminal-Digit system encrypts the patient’s identification with the use of numbers. Both systems require a significate amount of space but overall, the Terminal-Digit system is a more efficient system.
The purpose of this paper is to highlight the ethical challenges that could be experienced by professional nurses. To set the context of discussion, background is provided in relation to a professional nurse signing her name to a preprinted prescription form as asked by a physician and its relevance of how the board of nursing should find in such a case. The possible ethical challenges for the nurse is the implication of being charged with professional misconduct. The paper focuses mainly on issues relevant to professional misconduct by the nurse and physician.