Part 1
Change the medical terms in a progress note for a patient with a skin condition into common terms. Spell all medical and common terms correctly on the provided template.
The first step in completing this assessment is to review how to build a medical term. A medical term is built from three parts. The first part is the prefix or the beginning of the word. The second part is the word root or the main part of the word. The last part is the suffix or the ending of the word.
This assessment also covers the following body systems:
Musculoskeletal
Definition: Is the muscles and bones
Integumentary
Definition: Is the skin.
Then you will examine the skin, muscles, and bone systems. You will focus on diagnosis and treatment of the skin system. The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold.
In the assessment, you will review a progress note. Progress notes are common documents found in health care records in doctors’ offices and in hospitals. The first step is to identify the medical terms in the progress note. Then, you will change the medical terms that you found into common terms.
Your suggested resources provide study tips, explain the structure of medical terminology, and address skin, muscles, and bones conditions, diseases, treatment, and diagnostic studies.
Review the progress note below, including the subjective and objective notations. Next, download the and complete all of the following on the template:
- Select 12 medical terms from the progress note.
- On the template, place one term per line. For example: Actinic keratosis should not be on the same line, Actinic should be on one line and keratosis on a second line.
- Change the 12 selected medical terms into commonly used terms.
- Use medical terminology skills to break the medical term into its word parts. For example: keratosis is kerato, which means horny tissue and osis, which means condition of. Putting these together keratosis means condition of horny tissue
- Select three drugs from the progress note. For each drug, identify a skin condition that the selected drug treats.
- Spell all medical terms, common terms, and drugs correctly.
Subjective: The patient is a 49-year-old female who comes in with the complaint of having bumps on her arms. She states some of the bumps have been there a long time. Recently the bumps have been increasing in number and size. She was last seen about two years ago for eczema and was prescribed cyclosporine, at that time. However, she did not have these bumps. The bumps are not itchy or painful.
Objective: Very pleasant, alert, and oriented x3 female in no apparent distress. A full integumentary exam of the upper arms was performed today. The left radial aspect demonstrated erythematous macules. The right ulnar aspect demonstrated actinic keratosis. Bilateral hands appeared dry with linear excoriation and fissuring of her fingertips. Bilateral upper arms demonstrated superficial and deep masses. Deep subcutaneous masses are mobile and may represent lipomas. Superficial masses appear to be sebaceous cysts.
Assessment and Plan:
- Actinic keratosis of the right ulnar aspect was treated with liquid nitrogen.
- Possible lipomas: Schedule surgical biopsy of larger masses.
- Sebaceous cysts: Punch biopsy performed today; await pathology report. Apply Neosporin to biopsy site.
- Start Hydrocortisone intensive cream.
- Start Prednisone as directed.
- Format: Ensure you complete all columns on the Skin Progress Note Template.
- Scoring Guide: Be sure to read the scoring guide for this assessment to understand how your faculty member will evaluate your work.
Part 2
Change the common terms found in the history and physical (H&P) into medical terms or abbreviations of a patient who presented to an emergency room with a number of issues. Spell all medical terms or abbreviations and common terms correctly on the provided template.
This assessment covers terms related to body systems, structures, and functions. The focus will be on the nervous system. But, included are the digestive system and psychiatry. The nervous system carries messages to and from the brain. The digestive system turns food into energy. Psychiatry is how the brain thinks.
Your resources address diseases and treatments for the nervous and digestive systems, and information on psychiatry.
In the assessment, you will review a history and physical (H&P) report. This is a common document found in acute care settings. You will change the common terms found in the H&P into the correct medical terms.
Review the H&Pbelow for a patient who presented in the emergency room with a number of issues.Pay close attention to the history of present illness (HPI), past medical history, medications, allergies, social history,family history, review of systems, physician exam,assessment, and plan.Next, download theand complete all of the following on the template:
- Select 12common termsfrom the H&P that can be changed into a medical term.
- Change the 12 selected common terms intomedical termsor abbreviations.
- The first column (right side) of the worksheet should be the common terms found in the H&P below.
- Common and medical terms should include structure/function terms, and body system terms.
- Select 3 common terms from the H&P that relate to a specialized area of medicine such as radiology or surgery (procedural terms).
- Change the 3 selected common terms into the medical term for the radiology or surgical procedure.
- Build your medical terms using word parts.
- Be sure that your common term means the same thing as your medical term. For example: problems breathing is dyspnea (problems = dys, breathing = pnea). Shortness of breath is not dyspnea. Dys does not mean shortness. However, shortness of breath can be abbreviated to SOB
- Be sure to spell the common and medical termscorrectly.
Patient H&P
History of Present Illness:
This is a 54-year-old female who presented to the emergency room with a headache in the back of her head and double vision. She also complains of being able to see only from half of her eye. These symptoms began suddenly while she was out walking her dog about 45 minutes ago. A family member brought patient directly to the emergency room for evaluation.
Past Medical History:
- High blood pressure.
- High cholesterol.
- Irregular, rapid heartbeat.
- IBS.
- Cholelithiasis with cholecystectomy.
Medications:
Diovan 80 mg with hydrochlorothiazide 12.5 mg daily.
Allergies:
None.
Social History:
Non-smoker, no alcohol.
Family History:
Both parents and older sibling died from a stroke. Grandparents had extensive colon polyps.
Review of Systems:
She has bilateral vision defects. Denies dizziness, weakness, or numbness. Denies shortness of breath, problems breathing, and chest pain. Denies nausea, vomiting, and blood in stool. No bladder or bowel changes. No edema or skin changes to arms and legs.
Physician Exam:
- General:Female patient who is alert.
- Vital Signs:Stable.
- Skin:No discoloration, no tissue breakdown.
- Head, Eyes, Ears, Nose, Throat:Pupils equal, round, and reactive to light;Chest:Clear.
- Heart:Irregular, rapid rhythm.
- Abdomen:No guarding, some tenderness related to the IBS.
- Arms and Legs:No leg swelling.
Assessment and Plan:
- Headache in the back of the head with vision changes: Obtain a computed tomography scan and magnetic resonance imaging scan. Depending on test results, an artery repair procedure may need to be considered.
- High blood pressure: Continue home meds.
- Irregular, rapid heartbeat: Continue home meds.
- Format: Ensure you complete all columns on the Patient History and Physical Template.
- Scoring Guide: Be sure to review the scoring guide for this assessment so you understand how your faculty member is going to evaluate your work.
Competencies Measured
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 common terms related to general structures and functions of the human body correctly.
- Change common terms related to general structures and functions of the human body into medical terms or abbreviations correctly.
- Competency 3: Use medical terminology and abbreviations related to body systems.
- Identify common terms related to body systems correctly.
- Change common terms related to body systems into medical terms or abbreviations correctly.
- Competency 4: Use medical terminology and abbreviations related to specialized areas of medicine.
- Identify common terms related to specialized areas of medicine correctly.
- Change common terms related to specialized areas of medicine into medical terms or abbreviations correctly.
- Competency 6: Spell and pronounce basic medical terms.
- Spell common and medical terms or abbreviations correctly.
Part 3
- Submit three potential health topics for a 30-minute educational session for patients of a family practice office.
In this assessment, you will choose the topic for a presentation that you will create for Assessment 6. You will play the role of a family practice office manager. Your office offers a 30-minute monthly educational session for patients. You have been asked to conduct next month’s presentation.This assessment will allow you to keep your presentation in mind. You will use terms from different assessments, and you will be evaluated on the use and pronunciation of medical terms.You have the chance to choose a topic that interests you. Select a topic (disease, condition, or procedure) where you can meet the required criteria. For example, you may want to focus on a digestive system disease. Other examples include diabetes management, coronary artery disease, acne. These are examples only. Choose the topic of interest to you. Maybe you have a specific condition and would like to learn more about it given all that you have learned about medical terminology throughout this course. Maybe a family member or friend has the condition.
This assessment is in preparation for Assessment 6, Health Topic Presentation. The purpose of this assessment is to ensure your topic is sufficient and appropriate for the Health Topic Presentation requirements.To help prepare for this assessment:
- Please review the Health Topic Presentation assessment instructions and scoring guide criteria presented in Assessment 6 as you consider the topics that interest you most.
- You may also want to view the to see a brief example presentation.
For this assessment, you will select three potential topics for the Health Topic Presentation (Assessment 6).
- Provide 23 sentences for each topic that explain how the topic affects health care in today’s environment.
Once you receive your faculty member’s approval on your topic, you will want to begin your research. Consult the for help on how to begin your research and identify credible sources.
Part 3
Identify misspelled medical terms found in a patient’s operative report. Use the template to correct the terms’ spelling and change them into common terms. Write a 12 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.
In this assessment we will look at terms from the genitourinary system. This includes the urinary system and the male and female reproductive systems.
This assessment consists of two parts. In Part One you will review an operative report. During this course you have already looked at a progress note and an H&P. In the operative report you review as part of this assessment, you will change the medical terms you find into common terms. You will also correct spelling errors that appear in the report. This will show your knowledge of diseases, treatments, and diagnostic tests associated with these important body systems.
In Part Two, you will write a 12-page paper that explains the different types of documentation in the health record. Knowing what is in, and the use of, each type of report is an important aspect of your role as a HIM professional.
There are two parts to this assessment. Please complete both parts on the Operative Report Template and submit the one document..
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 and complete all of the following on the template:
- Select 15 misspelled medical terms in the operative report and place them in Column 1.
- List one misspelled term per line.
- Place the correctly spelled medical term in Column 3.
- Change the 15 medical terms into commonly used terms in Column 2.
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 andinclude hemorhage, UTI, pielonephritis, cystitis, vaginitis, MI, DVT, PE, death, 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 were 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, 12-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 as needed for additional writing resources to help your write the paper portion of your assessment.
Part 4
Identify misspelled medical terms found in a patient’s operative report. Use the template to correct the terms’ spelling and change them into common terms. Write a 12 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.
In this assessment we will look at terms from the genitourinary system. This includes the urinary system and the male and female reproductive systems.
This assessment consists of two parts. In Part One you will review an operative report. During this course you have already looked at a progress note and an H&P. In the operative report you review as part of this assessment, you will change the medical terms you find into common terms. You will also correct spelling errors that appear in the report. This will show your knowledge of diseases, treatments, and diagnostic tests associated with these important body systems.
In Part Two, you will write a 12-page paper that explains the different types of documentation in the health record. Knowing what is in, and the use of, each type of report is an important aspect of your role as a HIM professional.
There are two parts to this assessment. Please complete both parts on the Operative Report Template and submit the one document..
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 and complete all of the following on the template:
- Select 15 misspelled medical terms in the operative report and place them in Column 1.
- List one misspelled term per line.
- Place the correctly spelled medical term in Column 3.
- Change the 15 medical terms into commonly used terms in Column 2.
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 andinclude hemorhage, UTI, pielonephritis, cystitis, vaginitis, MI, DVT, PE, death, 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 were 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, 12-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 as needed for additional writing resources to help your write the paper portion of your assessment.
Part 5
Change common terms contained in a patient’s discharge summary into medical terms or abbreviations. Identify five drugs appearing in the discharge summary and specify the usage reason for each drug on the provided template. Record yourself reading the patient’s discharge summary (12 single spaced pages).
In this assessment, you will focus your attention on the blood, heart, and lungs. The heart and blood forms the circulatory system. The blood picks up oxygen from the lungs and carries the oxygen to the cells in the body. The heart pumps the blood moving through the body. The respiratory system is the lungs and passageways that bring in oxygen. You will have a chance to show your knowledge of the purpose, parts, and functioning of these systems. In addition, you will show your knowledge of diseases, diagnostic studies, and treatments, including drugs.
In the assessment you will review a discharge summary. This is for a patient with cardiorespiratory disease. Show your command of medical terms, including your pronunciation of the terms through an audio recording.
You will record yourself pronouncing terminology in this assessment. If you have not yet set up a microphone and practiced recording, refer to Audio and Video in this Course in the Tools and Resources menu for information. Before you begin the assessment, set up your microphone or headset and practice using your equipment to ensure you are able to record and that your audio quality is adequate.
Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact to request accommodations.
Review the patient’s discharge summary below. Next, download the and complete all of the following:
Part 1
- Identify eight common terms contained in the discharge summary.
- Correctly change them into medical terms or abbreviations.
- Identify two common terms related to specialized areas for medicine (radiology, surgery, or procedures) in the discharge summary.
- Correctly change them into medical terms or abbreviations.
- Identify five drugs that appear in the discharge summary.
- Specify the reason each drug is used.
Part 2
- Record yourself reading the discharge summary with the correct medical terms.
- In your recording, you need to correctly pronounce all the medical terms.
- In addition, be sure touse appropriate tone, volume, and clarity forprofessional communication in the health care field.
- Include the link to your recording in the Discharge Summary Template when you submit it.
Discharge Diagnosis
- Non-ST-elevation myocardial infarction.
- Moderate coronary artery disease.
- Stroke.
- High blood pressure.
- An abnormally high concentration of lipids in the blood.
- Chronic obstructive pulmonary disease.
- Chronic systolic congestive heart failure.
Procedures
Left heart catheterization, medical imaging test to determine cardiac function in the left ventricle, medical imaging used to visualize coronary arteries with stent placement, computed tomography scan, magnetic resonance imaging scan, posterior artery in the brain repair with stent placement.
Brief History
This 72-year-old male presented to the emergency room with chest pain, shortness of breath, and left arm numbness. Patient has a history of high blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure. In the emergency room, troponin levels and EKG results came back positive for Non-ST-elevation myocardial infarction. Patient was taken directly to the cardiac catheterization lab.
Past Medical History
High blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure, asthma as a child, previous right total knee replacement.
Medications
Norvasc, Lipitor, Lasix, Cozaar, oxygen dependent.
Family History
Patient is adopted and does not know family history; all children are healthy.
Social History
Former smoker, no alcohol or illegal drugs.
Allergies
Penicillin, Sulfa.
Physical Exam
GENERAL: Alert and oriented X3.
HEENT: Normocephalic and atraumatic, blindness over half the field of vision.
LUNGS: Few rales in lower lobes.
HEART: RRR without murmur.
ABDOMEN: Soft, non-tender, without swelling or masses.
EXTREMITIES: 2+ edema in lower extremities, no cyanosis.
Hospital Course
This is a 72-year-old male who was taken directly to the cardiac catheterization lab from the emergency department due to an evolving Non-ST-elevation myocardial infarction. A 98% close to the center right coronary artery lesion was treated with a Cypher 3.5 x 13 mm stent. The left descending artery showed 35% stenosis, and the left circumflex artery showed 25% stenosis. The image of the left ventricle demonstrated an ejection fraction of 40%. Following the procedure, the patient was admitted to the telemetry unit for observation. He remained in stable condition without chest pain but developed an irregular, rapid heartbeat. The next day, the patient complained of a severe headache in the back of his head with double vision and only being able to see from half of his eye. The patient was taken for a computed tomography scan and magnetic resonance imaging scan, which showed a blood clot blocking the posterior artery in the brain. The patient was taken back to the catheterization room where a catheterization of the head artery was performed to remove the blood clot and to place a stent to keep the vessel open. The patient is being discharged home on routine meds to follow up with a primary care physician within 7 days.
- What to Submit: Submit the Discharge Summary Template with a link to your recording in the document.
- Format: Use the Discharge Summary Template.
- Scoring Guide: Be sure to read this assessment’s scoring guide, so you understand how your faculty member will evaluate your Discharge Summary Template.
Part 6
Record a 30-minute slide presentation (10 to 15 slides) on a health topic of your choosing to present to patients of a family practice clinic.
In this final assessment, remember that you are a family practice office manager. Your office offers a 30-minute monthly education session for patients. You have been given the chance to present at next month’s session.
In Assessment 3, your faculty member approved your topic. Use credible resources to learn about your topic. Prepare a slide presentation with speaker notes for your education session. You will also submit an audio recording of your presentation.
You have been preparing for this project by researching the health topic, disease, or syndrome your faculty member approved in Assessment 3. If you have not yet done so, be sure to do the following:
- View the media piece. It provides a brief example of a project presentation.
- Complete your research on the health topic of your presentation. Consult the for research tips and help in identifying credible resources.
- You will use PowerPoint (or another slide presentation tool of your choice). To prepare, see the PowerPoint information provided in the Tools and Resources menu.
- You will also use speaker notes along with your presentation. Use the writing resources found at the as needed.
- If you choose to use Kaltura to record your presentation, be sure to review the information provided in Audio and Video in this Course in the Tools and Resources menu. If you use another recording application, you can upload your MP4 video file to your Media Gallery in the courseroom.
Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact to request accommodations.
- Record a presentation so that your slides are visible and your voice is recorded. It is optional to have your webcam in use to record your face.
- Your presentation should not exceed 20 minutes in length (average length is about 10 minutes).
- In your assessment submission, include the PowerPoint file with a link to the recorded presentation on the first slide. This is the link your faculty member will follow to view your presentation.
- Use the PowerPoint speaker notes as a transcript. Keep in mind that your slide should only contain the highlights. Place the details into the speaker notes.
Presentation Content
In your presentation, you should define and describe your topic and present information about it, including causes, signsand symptoms, at-risk populations, prognoses, diagnostic and testing procedures, treatment protocols, support systems, and prevention. Be sure to address body structure and function, pharmacology, and body systems related to your chosen topic.
You will be graded according to how well you demonstrate the course competencies, which will be measured by the following criteria and requirements:
- Pronounce medical terms properly.
- Spell health care terms correctly.
- Use medical terminology related to pharmacology or other treatment to a health topic.
- Use medical terminology related to the structure and functions of the human body to a health topic.
- Use medical terminology related to human body systems to a health topic.
- Use medical terminology related to a specialized area of medicine to a health topic
- Format: Submit the PowerPoint slides with a link to the recording on title slide. Add your speaker notes in the Notes sections of each slide.
- Professional presentation: Presentation should be of professional design, clearly written, and generally free of grammatical errors.
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