Carefully review the operative report for a patient who is having a sling
replacement to treat urinary frequency and incontinence. Next, complete the all
of the following on the Operative Report Template- I will attach 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
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, one-to-two-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.   
Additional Requirements
Part One: Operative Report
 Format: Ensure you complete all columns on the Operative Report Template.
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. 
 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

Make sure the assessment address the following:

  1. Identify all medical terms related to body systems, without errors.
  2. Translate all medical terms related to general structures and functions of the
    human body into common terms, without errors.
  3. Identify all medical terms related to body systems, without errors.
  4. Translate all medical terms related to body systems into common terms, without
  5. Describe the purpose and contents of some of the types of documentation that
    are part of the health record, and provide examples to show the impact of
    incomplete and inaccurate health records.
  6. Identify settings where the documentation is used and provide example to show
    the impact of failing to consistently use complete and accurate health records.
  7. Identify at least 15 misspelled medical and common terms.
  8. APA format

Answer Preview

APA Format,935 words

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