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PS medical term

ALL PARTS HAVE TO BE COMPLETED

Part 1 100-200 words

Primary Task Response: A patient may be referred to a medical specialty clinic for treatment. For that visit, an outpatient specialty note is prepared that follows the pattern for most medical notes and records. The record is referred to as a SOAP note, which stands for subjective, objective, assessment and plan (SOAP). The clinician will review and document what the patient states is his/her problem or concern (subjective), perform an exam that might include laboratory tests and imaging studies and document the results (Objective), review and analyze the information (Assessment) as a diagnosis or list of possible diagnoses, and formulate a plan of action (Plan) such as treatment options or need for further testing. This becomes the record of that visit and a part of the patient’s electronic health record (EHR).

Click on the EHR Orthopedic Clinic Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHEMENT NOTE

  • Read the EHR Orthopedic Clinic Note
  • Define the bolded terms and abbreviations in the EHR Orthopedic Clinic Note.
  • Summarize for the patient in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Orthopedic Clinic note means.
  • What is the function of the musculoskeletal system?

Part 2 100-200 WORDS

Primary Task Response: When a patient is seen in the emergency department (ED) of a hospital, that visit is documented in an emergency department visit note. The ED note must be succinct, but complete. This is because the physician and patient encounter in the ED is the basis for continued care (admission or follow-up) by providers outside of the ED. It is also important for coding and billing that the information be accurate and complete in order to obtain proper reimbursement. This is true for all health records and documentation.

Click on the EHR Emergency Department Visit Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHMENT NOTE 2

  • Read the Emergency Department Visit Note.
  • Define the bolded terms and abbreviations in the EHR Emergency Department Visit Note.
  • Summarize for the patient and his/her family in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Emergency Department Visit Note means.
  • What are the major organs of the respiratory tract and what is the function of this body system?

Part 3 100-200 words

Primary Task Response: After surgery at the time of discharge, the patient may be scheduled for a post-operative clinic visit or a call by a surgical specialty nurse or physician assistant. A surgery follow-up note documents that visit or phone call. The practitioner in the surgeon’s office/clinic will document the patient’s history and exam results as well as the evaluation and plan for further treatment/management.

Click on the EHR Surgery Follow–Up Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHMENT NAMED NOTE 3

  • Read the surgery follow-up note.
  • Define the bolded terms and abbreviations in the EHR Surgery Follow-Up Note.
  • Summarize for the patient in your own words (laymen’s terms) what each section (Subjective, Objective and Impression/Plan) of the Surgery Follow-Up Note means.
  • What is the function of the endocrine system in general? What is the function of the thyroid gland? Besides the thyroid gland, what are the other organs of this system?

Part 4 100-200 words

Primary Task Response: When a patient is discharged from a healthcare facility, a Discharge Summary is created to provide information and a plan of care to the patient as well as the care providers in the patient’s next setting of care. Discharge Summaries should include the reason why the patient was initially seen or admitted to the facility, what was found, the procedures or treatments that are administered to the patient, the patient’s condition on discharge, instructions for the patient and family, and the attending physician’s signature.

Click on the EHR Discharge Summary link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHMENT NAMED NOTE 4

  • Read the Discharge Summary.
  • Define the bolded terms and abbreviations in the EHR Discharge Summary.
  • Summarize for the patient in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Discharge Summary means.
  • What is the function of the urinary system and the major organs of this system?
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