Stacy Schmidt

HINT 110
June 10, 2014
Case Study Page 103

Medical Documents to Review

Progress Note 1

Patient: John Smith Record#: 019238
2/15/XX

S John was admitted on 2/13/XX. He is admitted because of a fractured pelvis. He also has a
history of arteriosclerotic dementia.
O He is alert, disoriented. Vital signs: BP (Blood Pressure)-112/60, P(Pulse)-76, R-18, W-133.
Lungs good inspiratory effort, no adventitious sounds.
Heart regular rhythm with systolic murmur unchanged. The nurse stated that his BP (Blood
Pressure) is high. I am increasing his ACE inhibitor because of elevated blood pressure.
A Arteriosclerotic dementia, IHD with dysrhythmia, depression.
P Monitor BP (Blood Pressure) and follow up in the morning,
Brain Jones, MD

Progress Note 1

Patient: Samantha Woods Record#: 229991
2/15/XX

Samantha is being admitted because of uncontrolled diabetes. She has had a left CVA
(Cardiovascular Accident (stroke)) with right-sided hemiparesis one year age.
O She is alert, oriented. Vital signs: BP (Blood Pressure)-118/64, P(Paul)-88, R-20, W-238.
Lungs - clear, no adventitious sounds, good bilateral air entry.
Heart regular rhythm with systolic murmur unchanged. She does not ambulate but can
transfer.
Her blood sugar levels are elevated, and I am adjusting her insulin. A referral is being sent to a
registered dietician to monitor her food intake. Blood pressures are slightly elevated.
A Diabetes mellitus, insulin dependent, uncontrolled, and HT.
P Continue to monitor blood sugar levels and refer to registered dietician; increase the
morning insulin
Julia Gymastro, MD

History and Physical 3

Patient: Susan Smith Record#: 495867
2/15/XX

A year ago, Souzan was admitted after fracturing her left hip. She underwent rehab and was
able to return home. She does have dementia as well as heart disease and glaucoma. She is
being admitted today because she is complaining of chest pain that radiates down her left arm.
CBC (Complete Blood Count) and additional lab work has been ordered, results pending. She
also has quite a bit of problems with muscle spasms, in her legs, and she was given a very low
dose of Robaxin, which has proved to be helpful.

Review of systems noncontributory secondary to dementia.

General status reveals an alert person. Vital signs: BP (Blood Pressure)-153/77, P(Pauls)-87, R-
28, W-122. She is 52.

HEENT head normocephalic.
Eye cornea clear, conjunctivae pale pink, sclera nonicteric. Pupils react to light.
Neck supple, carotids without bruit, no lymphadenopathy or thyromegaly.
Lungs clear to auscultation, no wheezes, rhonchi, or rales.
Hearts regular rhythem without murmur, rubs, heaves, or gallops. Distal pulses palpable
bilaterally. No cyanosis, clubbing, or edema.
Breasts no masses palpated.
Abdomen soft, nontender, nondistended. Bowel sounds active.
Rectal no stool obtained for guaiac testing.
Musculoskeletal functional range of motion of her joints including the left hip. She transfers
and walks independently with the use of a walker.
Neurological cranial nerves 2 12 grossly intact bilaterally. She is alert and oriented to
person. She follows finger to nose exercise test. No Babinski. Reflexes physiologic.
Plan of Care for admission
1. For her chest pain request cardiac consult
2. For her muscle spasms, continue medications q.d. (Daily), monitor effectiveness.
3. For her hypertension, continue to monitor blood pressure and adjust medications as
indicated.
Review following cardiac consult
Francis Urster, MD


Summary
Case Study for this week was all about abbreviation being used correctly in a medical
document at Sunny Valley Hospitals. The use of abbreviations shortens length of many words,
this really help healthcare professionals in saving time spent in writing notes. An abbreviation
however in a document does not always provide positive contributions due to misconceptions,
misunderstandings, and misinterpretations leading to commitment of errors in the practice.
Similarities in abbreviations for instance could root to a grave mistake. For instance lets take
q.d. which was shown in the record above, an inscriber would like to indicate as daily could be
erroneously interpreted as q.i.d. which means four times a day. Either way these two
abbreviations could cause an over dosage for some medications taken four times a day instead
of just once, thats why theyre on the Joint Commissions Do Not Use list and should be
written out for better understandings and avoiding confusion. Though some abbreviations
above can be easily understood clearly and exactly as to what meaning they communicate,
these abbreviations where found on table 4-7 in the Essentials of Health Information
Management book.
The abbreviation list should be approved upon the facility policies and be used during
the appropriate times. Avoiding the Joint Commission Do Not Use abbreviation list will help
for better clarifications to just spell the words out and avoid a conflict in the medical record.
After reading and looking through the documentation I have a better understanding of why and
how abbreviations are being used throughout a document in the medical records. In conclusion
abbreviation should be used appropriately throughout a patients medical record and for better
assistants in providing the correct of care from the facility.