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Lesson 10 medical terminology
Common medical terminology
Lesson 10 medical terminology
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Jane Dare, if it weren’t for her medical record she wouldn’t have been able to find out what was wrong with her. The doctors who took care of Jane made sure to have all the abbreviations and correct medical terms on her record so that they would be able to let her and her family know what she had. The doctors were able to let her know what medications she should be taking and how much of each medication because they had the correct abbreviations. If there were any incorrect abbreviations in the health record, they may have diagnosed her with something that she didn’t actually have. Or the doctors could’ve given her prescriptions to medications she wouldn’t have needed. It is so important that they use correct abbreviations and correct terms
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.
This quote centers Henrietta Lacks’ story around the same questions that have driven the Doctoring course: What does it mean to care for others? And how do we ensure that we care for our patients first as people, rather than as a disease? In many ways, Henrietta Lacks’ story is a textbook case in how not to be a good physician. In examining and learning from her story through the lens of Doctoring, we can inform our own practice and
As a little girl, she first found her life’s calling when she took care of her brother David after an accident. He had been helping to build a barn when he flipped and fell to the ground. Doctors had come to help, but he did not get any better. Eleven year-old Clara became David's nurse, administering his medicine and even applying and removing leeches when the doctors suggested it might help. Clara stayed home from school for two years to take care of her brothe...
I have been aware of medical errors for some time now. While in nursing school I have heard many stories from classmates and instructors of instances where people they knew, or loved ones had been either harmed or died because of a medical error. I have had experiences with medical errors. When I was in the hospital for the birth of my first child, the nurse that came to change out my IV bag did not check the
The misfortunes Jane was given early in life didn’t alter her passionate thinking. As a child she ...
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
...iately discovered and the patient was fine, but had there been proper communication between the healthcare staff, such blunders could have been avoided altogether (Dolanksy, 2013).
Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
There are several types of medical errors. Those errors are including, but not limited to: Treating the wrong patient; administering the wrong medicine to the patient; doing surgery on the wrong part of the body; extraction of wrong tooth; forgotten a surgical object inside the body (gauge in abdomen for example); fake doctors in Africa. Many of those errors are
We learn that Jane is a young girl who is a victim of emotional and
Larry and Dana Smith, a couple who had insurance, but due to deductibles and co-payments to the hospitals they had to sell their home and move to their daughter’s place. Frank at the age of 79 was working at a super store because his insurance was not paying for the all medicines he required. There was another lady who had health insurance, but it got cancelled after she was diagnos...
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.
patient history is neglected resulting to a serious health crisis or ever death and lawsuits.
Correction (defects): Adverse drug reactions. Readmission because of inappropriate discharge. Repeating tests because of incorrect information. Waiting Waiting for doctors to discharge patients. Waiting for the test results.