Professional Practice Activity - Essay Example

Professional Practice Activity The essay aims to address a two-fold objective to discuss to study the health record of Jane Dare; and (2) to discuss the advantages and disadvantages of using acronyms and medical abbreviations in a patient’s record. Professional Practice Activity Define the following terms in the proper context for the chart of Jane Dare. Jane Dare Health Record Term Definition 1. CONGESTIVE HEART FAILURE This is a chronic condition in which the heart is unable to pump out all of the blood that it receives. 2. LEFT PLEURAL EFFUSION A pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity 3. NONCONTRIBUTORY Making no contribution to a medical diagnosis 4. FUNDOSCOPIC The act of examining the fundus of the eye, as with an ophthalmoscope or with a biomicroscope and slit-lamp 5. SUPPLE Readily adaptable or responsive to new situations 6. CRACKLES A small, sharp sound heard on auscultation 7. BENIGN A condition, tumor, or growth that is NOT cancerous. This means that it does not spread to other parts of the body and it does not change or destroy nearby tissue. 8. VOIDED Having the inner part cut away or left vacant with a narrow border left at the sides —used of a heraldic charge 9. SELF-CARES A key concept in health promotion and refers to decisions and actions that an individual can take to cope with a health problem or to improve his or her health. 10.COGNITIVE Pertaining to the mental processes of perception, memory, judgment, and reasoning, as contrasted with emotional and volitional processes. 11.CARDIOMYOPATHY Cardiomyopathy refers to diseases of the heart muscle. These diseases enlarge your heart muscle or make it thicker and more rigid than normal 12.PSYCHOTROPIC Having an altering effect on perception, emotion, or behavior. Used especially of a drug. 13.AMBULATE To move from place to place 14.VERTIGO Refers to the sensation of spinning or whirling that occurs as a result of a disturbance in balance (equilibrium). 15.ISCHEMIC An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery 16.GAIT A particular way or manner of moving on foot 17.TWO STEP MANTOUX 18.STANDING ORDERS An order or rule held to be in force until specifically changed or withdrawn, especially a regulation relating to military or parliamentary procedure. 19.TYMPANIC Pertaining to a structure that resonates when struck; drum-like, such as a tympanic abdomen that resonates on percussion because the intestines are distended with gas. 20.CATHETERIZATION The introduction of a catheter through the urethra into the urinary bladder. 21.CERUMEN The brownish yellow, waxy secretion of the ceruminous glands of the external auditory meatus; earwax. 22.DYSPNEA Difficulty breathing occurs frequently with increased activity 23.PURULENT Containing, discharging, or causing the production of pus: a purulent infection. 24.HYDROACTIVE Physiotherapy practiced in warm water and can help relieve aches and pains mobilize stiff joints and strengthen weak muscles 25.BILATERALLY Having or formed of two sides; two-sided Reference Kozier, B. & Erb, G. (2006). Glossary. Fundamentals of Nursing Concepts and Practice (7th ed.) (p.1445-1467). New Jersey: Pearson Education, Inc. Publishing Professional Practice Activity Instructions Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report. Abbreviation Letters Represent Context Definition or Application within the Patient’s Chart Source Document 1. ICD International Classification of Disease Is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use Face Sheet 1. CM Case Manager A healthcare professional who assists in monitoring the financial aspects of your care, including insurance coverage and discharge planning Face Sheet 1. N/A Not Applicable Can’t be applied; irrelevant or inappropriate Face Sheet 1. ER Emergency Room The section of a health care facility for providing rapid treatment to victims of sudden illness or trauma Face Sheet 1. C/O Complaint of Chief Complaint, the reason why he/she hospitalized Face Sheet 1. SOB Shortness of Breath A common symptom of allergy, infection, inflammation, injury, or certain metabolic conditions.  Face Sheet 1. Mg milligrams A unit of mass equal to one thousandth (10 -3) of a gram.  Face Sheet 1. Po Per orem/by mouth Medications taking orally Face Sheet 1. Tid Thrice a Day As in taking a medicine three times daily. Face Sheet 1. Qd Each Day Taking the medicine everyday Face Sheet 1. Qod Every other day . As in taking a medicine every other day. Face Sheet 1. Qhs At each bedtime. As in taking a medicine each bedtime Face Sheet 1. Tabs Tablets A small flat pellet of medication to be taken orally. Face Sheet 1. Prn As Needed So that it is not always done, but done only when the situation calls for it (or example, taking a pain medication only when having pain and not without pain). Face Sheet 1. Cc Cubic centimeter A unit of volume equal to one thousandth (10-3) of a liter or to one milliliter. Face Sheet 1. HEENT Head, Eyes, Ears, Nose, Throat Specialization and treatment of head, eyes, ears, nose, throat Face Sheet 1. IV Intravenous A drug, nutrient solution, or other substance administered into a vein. Face Sheet 1. O2 Oxygen  A nonmetallic element constituting 21 percent of the atmosphere by volume that occurs as a diatomic gas, O2, and in many compounds such as water and iron ore. Face Sheet 1. EKG Electrocardiogram A graph of the electric activity of the heart X-Ray Report 1. CBC Complete Blood Count Specimens of venous blood, includes hemoglobin and hematocrit measurements, RBC count, WBC count, Red blood cell indices and a differential white cell count. Discharge Summary 1. ADL’s Activities of Daily Living Routine activities that people tend do everyday without needing assistance. There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and continence Discharge Summary 1. MSW Medical Social Worker An MSW requires you to graduate from a four-year college and attend school with an accredited MSW program for two years if youre attending full-time. Face Sheet 1. PT Physical Therapy The treatment of physical dysfunction or injury by the use of therapeutic exercise and the application of modalities, intended to restore or facilitate normal function or development Discharge Summary 1. HCL Hydrochloric Acid A clear, colorless, fuming, poisonous, highly acidic aqueous solution of hydrogen chloride, HCl, used as a chemical intermediate and in petroleum production, ore reduction, food processing, pickling, and metal cleaning. It is found in the stomach in dilute form. Progress Notes 1. VO Verbal Order Those that are spoken aloud in person or by telephone—offer more room for error than orders that are written or sent electronically.  Progress Notes 1. > More than Above normal Progress Notes 1. MOM Milk of Magnesia A milky white aqueous suspension of magnesium hydroxide, Mg(OH)2, used as an antacid and a laxative. Progress Notes 1. UA Urinalysis Laboratory analysis of urine, used to aid in the diagnosis of disease or to detect the presence of a specific substance, such as an illegal drugs Progress Notes 1. GI Gastrointestinal Of or relating to the stomach and intestines:  Progress Notes 1. IM Intramuscular Injections into muscle tissue that are absorbed more quickly than subcutaneous injections because of the greater blood supply to the body muscles. Progress Notes 1. D/T Diphtheria/ Tetanus Immunization/ Vaccination Progress Notes 1. DT Due To Time it will finish/ end Progress Notes 1. DP Diphtheria Pertussis Immunization/ Vaccination Progress Notes 1. UTI Urinary Tract Infection Inflammation of the bladder, ureters or urethra Progress Notes 1. OT Occupational Therapy The use of productive or creative activity in the treatment or rehabilitation of physically or emotionally disabled people. Discharge Summary 1. LOA Leave of Absence Approved absence period from work without loss of seniority or other job-related perquisites. A leave of absence is often granted to employees for particular purposes, such as attending an educational program or performing a special research project. Progress Notes 1. N/G Nasogastric Tube  Passed through the nares (nostril), down the esophagus and into the stomach. Progress Notes 1. G-tube Gastric Feeding Tube A tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition. Progress Notes 1. BP Blood Pressure The force exerted on arterial walls by blood flowing within the vessel Progress Notes 1. P Pulse A wave of blood created by contraction of the left ventricle of the heart Progress Notes 1. R Respiration The act of breathing, transport of oxygen from the atmosphere to the body cells and transport of carbon dioxide from the cells to the atmosphere Progress Notes 1. T Temperature Reflects the balance between the heat produced and the heat loss from the body, measured in heat units called degrees Progress Notes 1. CPR Cardiopulmonary Resuscitation Is a combination of oral resuscitation (mouth-to-mouth breathing), which supplies oxygen to the lungs, and external cardiac massage (chest compression) which is intended to reestablish cardiac function and blood circulation Progress Notes 1. PERL Pupils Equal and Reacting to Light Pupils are equal and reacting to light Progress Notes 1. NAS No Added Salt A form of diet for patient with CHF Face Sheet 1. 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 1. TO Task Order Supplementary contractual and obligating document that usually includes task description, and is used in task type contracts Progress Notes 1. PA Physical Assessment A medical examination to determine the condition of a persons health or physical fitness, especially for a specified activity or service. X-Ray Report 1. POA Power of Attorney Written legal authority given by one party  to act on the principals behalf Face Sheet 1. BM Bowel Movement The discharge of waste matter from the large intestine; defecation. Face Sheet 1. WCR/bca X-Ray Report Reference Dimov, V. (2006, November, 18). Cases Blog-Medical and Health Blog: Health News Updated Daily by Assistant Professor at University of Chicago, Internist, and Allergies, n.p. Retrieved on November 19, 2011 from http://casesblog.blogspot.com/2006/10/complete-list-of-medical-abbreviatons.html Professional Practice Activity "He had CP and SOB, was diagnosed w NSTEMI, had a PCI and is now in MICU." Whether you like or not, medical jargon is part of health care. Years ago, before I started my clinical rotations, I assembled a comprehensive list of all medical abbreviations I could find and memorized them by heart. It may sound strange but I actually liked using them. Also, for a short while, I was known as the "mnemonics guy" since (due to lack of other ideas how to better spend my time) I had made up about 800 mnemonics. Abbreviations and acronyms are sort of mnemonics; they save time and create confusion. Pretty much everybody who works in health care knows CHF and COPD but how about AOCD (anemia of chronic disease)? (Dimov, 2006, n.p.). In the medical field, we studied the different medical acronyms and abbreviations that we used in our duties as a health care professional, but the question is what are the advantages and disadvantages of using it? And when is the time we should limit the use of medical jargon? Based from my experienced, when I had my duty days when I was still a student nurse, its find difficult for me, reading the chart of the patient especially if that patient stays almost a month in the hospital. Honestly, I have many questions and I am still confused for some of the medical abbreviations that the physician used. I always asked my clinical instructor to be sure. As far as I observed, some of the advantages of using medical acronyms are, first, it could save time and effort for all health care professional, especially if there are many patients that needs to attend. In addition, abbreviations are commonly used in medical records to save time and space when writing medical information in a patients medical record, file or for prescriptions. Many medical conditions and drugs have long complicated names that would take time to completely write on a patients chart or script if abbreviations were not used (Easay, 2011,n.p). Errors with abbreviations for certain medical terms, conditions and drugs can lead to various types of medical errors. Medical errors are typically caused by illegible writing and misrepresentations of some types of abbreviations when providing treatments or filling a prescription (Easay, 2011, n.p). With this issue, we should limit the use of acronyms and abbreviations to prevent from errors and mistakes that could greatly affect the life of our patient, like in the case of Jane Dare. How could Janes medical records be affected by mistakes? As I review the health record of Jane Dare, I can conclude that Dare’s documents can really affected by some errors in abbreviations. For example, MOM which stands for Milk of Magnesia, for some who first encounter this acronym they would think that it is not a form of medication. Another one is NAS, No Added Salt which in the first I read it, I did not think that it is a form of diet for patient who had CHF Congestive Heart Failure. The three most common types of abbreviation-related errors were prescribing, improper dose/quantity, and incorrectly prepared medication. The most common abbreviation resulting in a medication error was the use of "qd" in place of "once daily” and "U" for units, "cc" for mL, "MSO4" or "MS" for morphine sulfate, and decimal errors (Molen, 2010, n.p.). These are all part of health record of Jane Dare, that’s why Jane’s record will be affected of mistakes. References Dimov, V. (2006, November, 18). Cases Blog-Medical and Health Blog: Health News Updated Daily by Assistant Professor at University of Chicago, Internist, and Allergies, n.p. Retrieved on November 19, 2011 from http://casesblog.blogspot.com/2006/10/complete-list-of-medical-abbreviatons.html Easay, C. (2011). eHow Health: Abbreviations Used in Medical Records, n.p Retrieved on November 20, 2011 from http://www.ehow.com/about_5516731_abbreviations-used-medical-records.html Molen, E.K. (2010, November 10). Study Blames Abbreviations For Medication Errors: Medical News Today, n.p. Retrieved on November 20, 2011 from http://www.medicalnewstoday.com/releases/80815.php. Read More