Mastering Medical Terminology- Identifying Key Terms for Human Body Structures and Functions

Mastering Medical Terminology- Identifying Key Terms for Human Body Structures and Functions

Progress Note

A progress note documents a patient’s current status and response to treatment during a hospital stay or course of care (Christman & Ernstmeyer, 2021). It contains information on the patient’s vital signs, symptoms, any new orders, treatments provided, and the clinician’s assessment and plan. Progress notes are used in inpatient hospital settings, ambulatory clinics, and other healthcare facilities to track a patient’s ongoing care.

History and Physical (H&P)

A history and physical (H&P) document a patient’s comprehensive medical history, review of systems, physical examination findings, and the clinician’s assessment and plan. It provides baseline information for diagnostic workups and planned treatments. H&Ps are commonly performed when a patient is admitted to a hospital, at the start of outpatient care, pre-operatively, or when there is a significant change in a patient’s condition. They are used across all healthcare settings.

Operative Report

An operative report provides a detailed account of a surgical procedure. It includes the pre-and post-operative diagnoses, procedure name, surgeon’s name, anesthesia type, operative findings, techniques used, specimens removed, complications, and post-operative conditions. Operative reports become a permanent component of a patient’s medical record and are used for billing, quality review, and medical-legal purposes (Wang,  et al., 2012). They are used in hospitals, ambulatory surgery centers, and any facility where surgical procedures are performed.

Discharge Summary

A discharge summary summarizes the key events and information from a patient’s hospital stay or episode of inpatient care. It includes the admission reason, significant findings, procedures performed, treatment course, condition at discharge, discharge instructions, and a final diagnosis. Discharge summaries facilitate communication and transfer of care between the inpatient and outpatient settings (Kind, n.d). They are created for all patients being discharged from a hospital.

Reference

Christman, E., & Ernstmeyer, K. (2021). Nursing fundamentals. XanEdu Publishing Inc.

Kind, A. J. H. (n.d.). Documentation of mandated discharge summary components in transitions from acute to subacute care. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). https://www.ncbi.nlm.nih.gov/books/NBK43715/

Wang, Y., Pakhomov, S., Burkart, N. E., Ryan, J. O., & Melton, G. B. (2012). A study of actions in operative notes. AMIA … Annual Symposium proceedings. AMIA Symposium, 2012, 1431–1440.

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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.

Mastering Medical Terminology- Identifying Key Terms for Human Body Structures and Functions

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.