Jane Dare's Medical Record is a simulation of a real health record. Take time to notice all of the different forms and all of the providers who document in the record. You may even notice a few errors. It is typically the Health Information Technician's job to find errors and have them corrected when necessary. Errors are never removed from a chart with white out, pen, cutting out, or any other means. An error can be corrected by putting a single line through the error with blue or black ink. You then correct the error next to it, initial it with your initials and the date that the error was corrected. Grammatical errors are generally not corrected.
Follow these steps, working with the Health Record and the two charts:
1. Download and review the Health Record of Jane Dare. (As you do so, note key abbreviations highlighted in yellow and key medical terms underlined in light green.)
• Health Record of Jane Dare
2. Now download and complete the following chart of abbreviations. (Note that the abbreviations listed here match those highlighted in yellow in Jane Dare's Health Record.)
• Jane Dare Health Record Abbreviations
Complete the chart of abbreviations, following the model below.
Example of how to complete the chart of abbreviations:
Abbreviation |
Letters Represent
|
Context Definition or Application within the Patient's Chart
|
Source Document
|
|
CHF
|
Congestive Heart Failure
|
This is a chronic condition in which the heart is unable to pump out all of the blood that it receives.
|
Face Sheet
|
3. Finally, download and complete the following chart of medical terms from the Jane Dare Health Record. (Note that in Jane Dare's record, these medical terms are underlined in light green.)
• Jane Dare Health Record Term
Evaluation
The activity will be evaluated on (1) Your correct interpretation of abbreviations in the first chart along with your understanding of the benefits and limitations of using abbreviations in a Health Record such as Jane Dare's; (2) Your accurate definitions of medical terms in the second chart.
For your summary, write a brief essay (2-3 paragraphs) in your own words about the benefits and limitations of the use of medical abbreviations. Include in your summary how the use of abbreviations supports the diagnosis or reason for Jane's encounter, justifies her treatment, and accurately documents her results. How could Jane's medical records be affected by mistakes? What would be a consequence of an abbreviation mistake in Jane's record? The summary should be free of spelling and grammatical errors.
Define the following terms in the proper context for the chart of Jane Dare.
Jane Dare Health Record Term
1. CONGESTIVE HEART FAILURE
2. LEFT PLEURAL EFFUSION
3. NONCONTRIBUTORY
4. FUNDOSCOPIC
5. SUPPLE
6. CRACKLES
7. BENIGN
8. VOIDED
9. SELF-CARES
10.COGNITIVE
11.CARDIOMYOPATHY
12.PSYCHOTROPIC
13.AMBULATE
14.VERTIGO
15.ISCHEMIC
16.GAIT
17.TWO STEP MANTOUX
18.STANDING ORDERS
19.TYMPANIC
20.CATHETERIZATION
21.CERUMEN
22.DYSPNEA
23.PURULENT
24.HYDROACTIVE
25.BILATERALLY