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HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System

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Capella University

HIM FPX 4610 Medical Terminology

Prof. Name

Date

Introduction

A patient’s medical records consist of various documents and forms essential for documenting their healthcare journey. These include visit notes, care authorizations, and insurance details. This discussion delves into four crucial types of documentation: progress notes, history and physical (H&P), operative reports, and discharge summaries. Each serves a distinct purpose, containing specific information relevant to the patient’s care trajectory. Maintaining accurate and comprehensive records is imperative for effective patient management.

Progress Note

A progress note serves as a comprehensive record of a patient’s visit, documenting details such as illness or injury, treatment progress, and diagnostic developments. These notes are standard across all hospital settings, providing vital information for continuity of care. Key components of a progress note include the date and time of the visit, identifying information, details of the encounter, and the signature of the documenting healthcare provider. While the format may vary between practices, the essential elements remain consistent (Columbia University, 2020).

History and Physical (H&P)

The History and Physical document offers insights into a patient’s medical history and current findings upon admission. It outlines the reasons for hospitalization, medical background, and factors leading to the current medical condition. This document aids caregivers in understanding the patient’s context, including historical data, examination findings, and proposed treatment plans. It is completed during the admission process, facilitating informed patient care (Goldberg, 2020).

HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System

Operative Report

An Operative Report details surgical procedures performed on a patient, including surgical team members, procedures undertaken, intraoperative findings, and post-operative diagnoses. This report is generated immediately following surgery and is crucial for documenting the surgical intervention comprehensively. It is utilized in both outpatient and inpatient surgical settings, ensuring accurate recording of surgical events and outcomes (Yale, 2009).

Discharge Summary

The Discharge Summary offers a comprehensive overview of the patient’s treatment history, encompassing identification details, present illness history, assessments, treatment plans, progress notes, and significant findings. This document serves various healthcare settings, including rehabilitation facilities and mental health institutions, providing a concise summary of the patient’s healthcare journey post-treatment.

References

Goldberg, C. (n.d.). UCSD’s Practical Guide to Clinical Medicine. Retrieved February 19, 2020, from https://meded.ucsd.edu/clinicalmed/write.htm

Guidelines For Progress Notes. (n.d.). Retrieved from http://www.columbia.edu/itc/hs/medical/medicine/GuidelinesforProgressNotes.pdf

MONTANA STATE HOSPITAL POLICY AND PROCEDURE Discharge Summary. (n.d.). Retrieved February 21, 2020, from https://dphhs.mt.gov/Portals/85/amdd/documents/MSH/volumei/healthinformation/DischargeSummary.pdf

HIM FPX 4610 Assessment 4 Operative Report: The Genitourinary System

Operative reports. (2009, April 1). Retrieved from https://medicine.yale.edu/news-article/1983/

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