Here you can read our free Guide of HIM-FPX 4610 Assessment Four Health Topic Approval.
Instructions of HIM-FPX 4610 Assessment Four Health Topic Approval
Operative Report
Identify misspelled medical terms in a patient’s operative report. Use the template to correct the terms’ spelling and translate them into common terms. Write a 1–2 page paper that describes the purpose and contents of some of the types of documentation used in the HIM field. Specify the settings in which these documents would be used.
Collapse All
Introduction
In this fourth assessment, we continue our focus on medical terminology, specifically on medical terminology related to the genitourinary system. This includes the urinary system and the male and female reproductive systems. The urinary system is also known as the renal system. It is a group of organs that filter excess fluid and other blood stream substances from the body.
This assessment consists of two parts. In Part One you will review an operative report. During this course you have already examined a progress note and an H&P. In the operative report you review as part of this assessment, you will translate the medical terms you find into common terms. You will also correct spelling errors that appear in the report. Completing this portion of the assessment will allow you to demonstrate your knowledge of how the genitourinary system works. You will also demonstrate your knowledge of diseases, treatments, and diagnostic tests associated with this important body system.
In Part Two, you will write a 1–2 page paper that analyzes the different types of documentation in the health record. Familiarity with the contents and use of each type of documentation is an important aspect of your role as a HIM professional.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
- Identify medical terms related to general structures and functions of the human body correctly.
- Translate medical terms related to general structures and functions of the human body into common terms correctly.
- Competency 3: Use medical terminology and abbreviations related to body systems.
- Identify medical terms related to body systems correctly.
- Translate medical terms related to body systems into common terms correctly.
- Competency 5: Analyze and define medical terminology as used in health information management.
- Describe the purpose and contents of some of the types of documentation that are part of the health record.
- Identify settings where the documentation is used.
- Competency 6: Spell and pronounce basic medical terms.
- Identify misspelled medical and common terms.
- Spell medical and common terms correctly.
- Competency 7: Communicate in a professional manner.
- Write clearly, with correct spelling, grammar, and syntax, and good organization.
- Provide citations and references in APA style.
Instructions
Part One: Operative Report
Carefully review the operative report for a patient who is having a sling replacement to treat urinary frequency and incontinence. Next, download the Operative Report Template [DOCX] and complete all of the following on the template:
- Select 15 misspelled medical terms in the operative report and place them in Column 1.
- Translate the 15 misspelled medical terms into commonly used terms in Column 2 correctly.
- Place the correctly spelled medical term in Column 3.
- Cite in correct APA style the references you used to perform your translation.
Preoperative Diagnosis: Urinary stress incontinence, cystocele.
Postoperative Diagnosis: Same.
Anesthesia: General.
History: This is a 49-year-old female with a history of a histerectomy and bilateral ophorectomy. She complains of urinarie frequency and incontinental. Options were discussed with patient, and she decided to proceed with a sling placement. Risks of the procedure were discussed. They include hemorhage, UTI, pielonephritis, cystitis, vaginitis, MI, DVT, PE, death, et cetera, and were deemed acceptable.
Operative Details: The patient was brought to the ER positioned, prepped and draped in the usual fashion. Time-out was called and patient identity and procedure being performed was validated. A Folley catheter was placed, and the bladder drained. Allis clamps were placed on the posterior vaginal muosa. A small incision was made, and the blader was lifted off of the vaginl mucosa. The cystcele was reduced. At this time, a minor enterocele was noted. Due to the small size, the interocele was not repaired. Bilateral stab incisions were made suprapublically and SPARC needs placed into the superpubic incisions and pulled through the vaginal incisions. The SPARC mesh was attached to the needles and pulled up through the insicions. The mesh was positioned against the mid-urethre, sutured into place, and cut below the surface of the sin. The skin was closed with 4-place suture; the vaginal incision was closed with 0-vicryl. The patient was transferred to the recovery room in stable condition.
Blood Loss: Minimal.
Part Two: HIM Terminology
Write a short, 1–2 page paper on some of the types of documentation used in the HIM field. Be sure your paper includes all of the following headings:
- Progress Note.
- History and Physical (H&P).
- Operative Report.
- Discharge Summary.
Under each heading, address each of the following:
- Describe the purpose of the document.
- Detail the contents included.
- Identify settings where the document would be used.
Consult the Capella Writing Center as needed for additional writing resources to help your write the paper portion of your assessment.
Additional Requirements
Part One: Operative Report
- Format: Ensure you complete all columns on the Operative Report Template.
- Scoring Guide: Be sure to read the scoring guide for this assessment so you understand how your faculty member will evaluate your work.
Part Two: HIM Terminology
- Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
- Title Page: You do not need to include a title page with your paper. You do need to label it HIM Terminology.
- Name: Include your name in the upper right-hand corner on your paper.
- Length: Approximately 1–2 typed and double-spaced content pages in Times New Roman, 12-point font, not including the reference page.
- References: Include a minimum of one citation of peer-reviewed sources in APA format.
Resources
This course has been completed and no further assessments may be submitted.
Use the resources linked below to help complete this assessment.
Collapse All
Genitourinary Systems
Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders. Available in the courseroom via the VitalSource Bookshelf link.
- Chapter 7, “Urinary System,” pages 215–256.
- Chapter 8, “Female Reproductive System,” pages 257–310.
- Chapter 9, “Male Reproductive System,” pages 311–342.
The Endocrine System
Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders. Available in the courseroom via the VitalSource Bookshelf link.
- Chapter 18, “Endocrine System,” pages 749–798.
Word Structure
Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders. Available in the courseroom via the VitalSource Bookshelf link.
- Appendix I, “Plurals,” page 981.
Health Information Management (HIM) Terminology
- Casto, A., Koehler, M., & Lockwood, F. (2017). Clinical terminology: Expanding career pathways for HIM professionals. Journal of AHIMA, 88(9), 50–55.
- Russo, R. (2004, October). Documentation and data improvement fundamentals. IFHRO congress & AHIMA convention proceedings. Retrieved from http://bok.ahima.org/doc?oid=60174#.Wl95E66nGUk
Additional Resources for Further Exploration
While this course has focused on medical terminology, keep in mind that the health care field expands beyond medical terminology. For example, the health information management field has terminology related to reimbursement, documentation, and the electronic health record. The Oachs and Watters textbook—an optional resource for this course—is a great place to learn more about this terminology.
Oachs, P. K., & Watters, A. L. (2016). Health information management: Concepts, principles, and practice (5th ed.). Chicago, IL: AHIMA Press. Available in the courseroom via the VitalSource Bookshelf link.
- Chapter 4, “Health Record Content and Documentation,” pages 97–140.
- Chapter 5, “Clinical Classifications, Vocabularies, Terminologies, and Standards,” pages 141–168.
Activity
Click Activity: The Genitourinary System to complete an interactive activity that will enable you practice the medical terminology associated with the male and female genitourinary systems and assess your knowledge of these important body systems. This additional practice will serve you well as you complete your assessment on this body system. Have fun and good luck.
This tool needs to be loaded in a new browser window
STEP-BY-STEP GUIDE on HIM 4610 Assessment Four Health Topic Approval
Introduction to HIM 4610 Assessment Four
This Owlisdom How-To Guide aims to assist students in completing an assignment focused on medical terminology, particularly related to the genitourinary system. The HIM 4610 Assessment Four Health Topic Approval involves reviewing an operative report, correcting and translating medical terms, and writing a short paper on health information management (HIM) documentation. This How-To Guide aims to demonstrate proficiency in identifying, translating, and correctly spelling medical terms and understanding different types of HIM documentation.
Select 15 misspelled medical terms in the operative report and place them in Column 1.
Correctly translate the 15 misspelled medical terms into commonly used terms in Column 2.
Place the correctly spelled medical term in Column 3.
Cite in the correct APA style the references you used to perform your translation.
Part One: Operative Report
For Part One of the HIM 4610 Assessment Four Health Topic Approval, we will find misspelled medical terms in the patient’s report and fill out the provided template. I am using the template by Capella University as an example.
- Review the Operative Report: Carefully read through the entire operative report to understand the context and identify any medical terms that may be misspelled.
- Identify Misspelled Medical Terms: Select 15 misspelled medical terms. Look for standard medical terms that seem incorrect or out of place.
- Translate Medical Terms: Translate each of the 15 misspelled medical terms into standard terms that are easily understandable by non-medical professionals. Use reliable medical dictionaries or online medical resources.
- Correct Spelling of Medical Terms: Provide the correct spelling for the identified misspelled medical terms. Double-check medical references to ensure accuracy.
- Cite References in APA Style: Cite the references you used to translate and correct the medical terms using APA style. For guidance on proper citation format, refer to the latest APA manual or online resources.
Example
Part Two: HIM Terminology Paper
Progress Note
Now, in HIM 4610 Assessment Four Health Topic Approval. We will describe how a progress note records a patient’s ongoing care and progress.
- Contents Included: Detail the typical contents, such as patient updates, clinical observations, and treatment plans.
- Settings of Use: Identify settings where progress notes are commonly used, such as hospitals and clinics.
History and Physical (H&P)
Here, in HIM 4610 Assessment Four Health Topic Approval. We will explain that an H&P document provides a comprehensive overview of the patient’s medical history and physical condition.
- Contents Included: Outline the contents, including patient history, physical examination findings, and initial diagnostic impressions.
- Settings of Use: Mention that H&P documents are used in various healthcare settings, including hospitals, outpatient clinics, and specialty care centers.
Operative Report
In HIM 4610 Assessment Four Health Topic Approval, The purpose of the Document is to describe an operative report that details the surgical procedure performed, including the steps taken and outcomes.
- Contents Included: List contents such as patient identification, preoperative diagnosis, surgical procedure, and postoperative diagnosis.
- Settings of Use: Indicate that operative reports are used in surgical settings, including hospitals and outpatient surgical centers.
Discharge Summary
Purpose of the Document: Explain that a discharge summary provides a summary of the patient’s hospital stay and instructions for post-discharge care.
Contents Included: Detail the contents, such as patient discharge condition, medications prescribed, follow-up instructions, and recommendations.
Settings of Use: Identify settings where discharge summaries are used, such as hospitals and rehabilitation centers.
Demonstration of Proficiency
Competency 2: Demonstrate the ability to identify and translate medical terms related to general structures and functions of the human body.
Competency 3: Show proficiency in identifying and translating medical terms related to body systems.
Competency 5: Analyze and define medical terminology in health information management, describing the purpose and contents of various documentation types.
Competency 6: Correctly identify and spell medical and standard terms.
Competency 7: Communicate professionally, ensuring clear writing, correct spelling, grammar, and proper APA citation.
Closing
Completing this HIM 4610 Assessment Four Health Topic Approval will enhance your understanding and proficiency in medical terminology, particularly concerning the genitourinary system. You will develop essential skills required in healthcare by identifying and correcting misspelled medical terms, translating them into everyday terms, and analyzing HIM documentation. Remember, the competencies outlined are designed to guide you through the assessment, ensuring a thorough understanding and practical application of medical terminology. In the next module of HIM-FPX 4610, we will explore Assessment Five on The Cardiorespiratory System.
