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this assignment consists of two parts. carefully review each part.Carefully review the operative report for a patient who is having a sling replacement to treat urinary frequency and incontinence. then complete the following on template provided: 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 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 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, 1–2 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.
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