Stacy SchmidtHINT 110

June 10, 2014Case Study Page 103

Medical Documents to Review

Progress Note 1

Patient: John Smith Record#: 0192382/15/XX

S – John was admitted on 2/13/XX. He is admitted because of a fractured pelvis. He also has a history of arteriosclerotic dementia.

O – He is alert, disoriented. Vital signs: BP (Blood Pressure)-112/60, P(Pulse)-76, R-18, W-133.Lungs – good inspiratory effort, no adventitious sounds.Heart – regular rhythm with systolic murmur unchanged. The nurse stated that his BP (Blood

Pressure) is high. I am increasing his ACE inhibitor because of elevated blood pressure.A – Arteriosclerotic dementia, IHD with dysrhythmia, depression.P – Monitor BP (Blood Pressure) and follow up in the morning, Brain Jones, MD

Progress Note 1

Patient: Samantha Woods Record#: 2299912/15/XX

Samantha is being admitted because of uncontrolled diabetes. She has had a left CVA (Cardiovascular Accident (stroke)) with right-sided hemiparesis one year age.

O – She is alert, oriented. Vital signs: BP (Blood Pressure)-118/64, P(Paul)-88, R-20, W-238. Lungs - clear, no adventitious sounds, good bilateral air entry.Heart – regular rhythm with systolic murmur unchanged. She does not ambulate but can

transfer. Her blood sugar levels are elevated, and I am adjusting her insulin. A referral is being sent to a

registered dietician to monitor her food intake. Blood pressures are slightly elevated.A – Diabetes mellitus, insulin dependent, uncontrolled, and HT.P – Continue to monitor blood sugar levels and refer to registered dietician; increase the

morning insulinJulia Gymastro, MD

History and Physical 3

Patient: Susan Smith Record#: 4958672/15/XX

A year ago, Souzan was admitted after fracturing her left hip. She underwent rehab and was able to return home. She does have dementia as well as heart disease and glaucoma. She is being admitted today because she is complaining of chest pain that radiates down her left arm. CBC (Complete Blood Count) and additional lab work has been ordered, results pending. She also has quite a bit of problems with muscle spasms, in her legs, and she was given a very low dose of Robaxin, which has proved to be helpful.

Review of systems noncontributory secondary to dementia.

General status reveals an alert person. Vital signs: BP (Blood Pressure)-153/77, P(Pauls)-87, R-28, W-122. She is 5’2”.

HEENT – head normocephalic.Eye – cornea clear, conjunctivae pale pink, sclera nonicteric. Pupils react to light.Neck – supple, carotids without bruit, no lymphadenopathy or thyromegaly.Lungs – clear to auscultation, no wheezes, rhonchi, or rales.Hearts – regular rhythem without murmur, rubs, heaves, or gallops. Distal pulses palpable

bilaterally. No cyanosis, clubbing, or edema.Breasts – no masses palpated.Abdomen – soft, nontender, nondistended. Bowel sounds active.Rectal – no stool obtained for guaiac testing.Musculoskeletal – functional range of motion of her joints including the left hip. She transfers

and walks independently with the use of a walker.Neurological – cranial nerves 2 – 12 grossly intact bilaterally. She is alert and oriented to

person. She follows finger to nose exercise test. No Babinski. Reflexes physiologic.Plan of Care for admission

1. For her chest pain request cardiac consult2. For her muscle spasms, continue medications q.d. (Daily), monitor effectiveness.3. For her hypertension, continue to monitor blood pressure and adjust medications as

indicated.Review following cardiac consultFrancis Urster, MD

Summary

Case Study for this week was all about abbreviation being used correctly in a medical

document at Sunny Valley Hospitals. The use of abbreviations shortens length of many words,

this really help healthcare professionals in saving time spent in writing notes. An abbreviation

however in a document does not always provide positive contributions due to misconceptions,

misunderstandings, and misinterpretations leading to commitment of errors in the practice.

Similarities in abbreviations for instance could root to a grave mistake. For instance let’s take

q.d. which was shown in the record above, an inscriber would like to indicate as daily could be

erroneously interpreted as q.i.d. which means four times a day. Either way these two

abbreviations could cause an over dosage for some medications taken four times a day instead

of just once, that’s why they’re on the Joint Commissions “Do Not Use” list and should be

written out for better understandings and avoiding confusion. Though some abbreviations

above can be easily understood clearly and exactly as to what meaning they communicate,

these abbreviations where found on table 4-7 in the Essentials of Health Information

Management book.

The abbreviation list should be approved upon the facility policies and be used during

the appropriate times. Avoiding the Joint Commission “Do Not Use” abbreviation list will help

for better clarifications to just spell the words out and avoid a conflict in the medical record.

After reading and looking through the documentation I have a better understanding of why and

how abbreviations are being used throughout a document in the medical records. In conclusion

abbreviation should be used appropriately throughout a patient’s medical record and for better

assistants in providing the correct of care from the facility.