Alamance-Burlington School System



3.02 What’s the Main Term? Name___________________ Handout Date ____________________Directions: Using the ICD-9-CM for reference, identify and underline the main term in each diagnosis listed below. 1.Open fracture, maxilla2.Congenital diaphragmatic hernia3.Diaper rash4.Dysplasia of the cervix5.Sleep apnea6.Intracranial abscess7.Congestive heart failure8.Acute cystitis9.Chronic maxillary sinusitis10.Impacted feces11.Upper respiratory infection12.Irritability of the stomach13.Elevated blood pressure14.Nontraumatic rupture of Achilles tendon15.Diabetic cataract16.Cushing’s Syndrome17.Vitamin B12 deficiency18.Trench mouth19.Webbed toes20.Intrinsic asthma in status asthmaticus3.02 ICD-9-CM Coding Name ___________________ Handout Date ____________________Directions: Use the ICD-9-CM Code book to assign the correct ICD-9-CM codes for the following diagnoses. Follow the Basic Steps of ICD-9-CM Coding.1.Allergic diarrhea __________2.Cholesterolosis of gallbladder __________3.Urethral chancre __________4.Cystic fibrosis __________5.Congestive rheumatic heart failure __________6.Viral meningitis __________7.Cleft lip and palate __________8.Pancytopenia __________9.Infantile cerebral palsy __________10.Anal fistula __________11.Acne vulgaris __________12.Dermatophytosis of the foot __________13.Hiatal hernia with obstruction and gangrene __________14.Mitral valve insufficiency __________15.Monocytic leukocytosis __________16.Lung mass __________17.Prolapse of the bladder, female __________18.Rupture of the gallbladder __________19.Venereal warts __________20.Gouty arthritis __________3.02 Understand health informatics II Name___________________ Handout Date ____________________Directions: Record notes and class discussion in your own words. Document informationCareer ResponsibilitiesClass DiscussionCommunicate informationManage health information systems3.02 Using Medical Abbreviations Name ________________________ Handout Date ________________________Directions: Translate the following patient scenario and rewrite the scenario using the definition of the abbreviation. Underline the definition.Katie was admitted to the ED with complaints of FUO, N/V, and SOB. She had had nothing po because the sx became worse pc. A CBC, UA, and BS were ordered. An intravenous line was started and she was made NPO. Her TPR was normal but her P had increased. After a few hours, it was determined that she could be OOB and the order for BR was discontinued. She was placed on cl liq and received more than gtts for lunch. Her initial Dx of R/O salmonella was amended as she tolerated the liquids. When all lab work returned WNL, she was discharged. On the way out of the ED, she had to complete the paperwork with her DOB and was given a Rx for nausea. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3.02 Medical AbbreviationsName ___________________Handout Class ___________________a beforeac before mealsad lib as desiredax axillary BR bedrestBS blood sugarBSE breast self-examCBC complete blood countcl liq clear liquidsDNR do not resuscitateDOA dead on arrivalDOB date of birthDx, dx diagnosisED emergency departmentFUO fever of unknown origingtt dropNPO nothing by mouthN/V, N&V nausea and vomitingp afterP pulse OOB out of bedpc after mealspo by mouthR respirationR/O rule outROM range of motionRx treatmentSOB shortness of breathSx symptomT, temp temperatureTPR temperature, pulse, respirationUA, U/A urinalysisWNL within normal limits3.02 Proofreading Exercise Name ___________________ Handout Date ____________________Directions: In the record below, circle misspelled words and identify missing words. Underline the misspelled words and write the corrected and missing words in the appropriate blanks. Consult medical and English dictionaries as necessary.1. The labratory testing of blood, urine, and1. ________________________2. other body fliuds and waste products plays a2. ________________________3. miner roll in modern diagnostic medicine. 3. ________________________4. The number of availabel tests increases 4. ________________________5. almost daily, and the range of diseses and 5. ________________________6. conditions able to be tested in labratory 6. ________________________7. studys continually broadens. Some mention 7. ________________________8. of labratory test results appears frequently 8. ________________________9. in history, in physical examintion reports 9. ________________________10. and nearly always in hospital discharge 10. _______________________11. summarys. Accordingly the medical11. _______________________12. transcirptionist must be familiar with the 12. _______________________13. general conceps of laboratory medicine as 13. _______________________14. well as with pecific tests. Diagnostic14. _______________________15. labratory procedures may be called tests,15. _______________________16. studies, or simply work (“lab studies, “ “lab16. _______________________17. word”). Phisicians may report that they17. _______________________18. ordered, got, ran, did, or (in the case of18. _______________________19. blood work) drew a test.19. _______________________20. Crohn’s disease is a chronic dysorder 20. _______________________21. which consists of inflamation of the 21. _______________________22. gastrointestinal track. It is most commonly 22. _______________________23. inflamation of the terminal ilium. The 23. _______________________24. exact cause is unknown, but possible 24. _______________________25. causes are allerges, imune25. _______________________26. disorders, and infections. Labratory tests 26 _______________________27. have not detected any bacteria or virus 27. _______________________28. responsable for causing Crohn’s disease.28. ________________________29. The patient experiences cramping,29. _______________________30. abdominal pain, nausea, diarrhea,30. _______________________31. abdominal tenderness, and weekness.31. _______________________32. Patience may be given intervenous fluids32. _______________________33. to provide nutrition while resting the bile. 33. _______________________34. Some patients require surgery if the bile 34. _______________________35. perforates,obstructs, or if there is35. _______________________36. massive hemorhage.36. _______________________3.02 Filing Records Name _______________HandoutDate ________________Alphabetic FilingAll personal names are transposed so that the last name is the primary indexing unit, first name second and middle name or initial is the third unit.April SmithSmith, AprilJesse W. BrownBrown, Jesse W. If filing identical names, use the city and street names to place in alphabetical sequenceDon S. Clay, Asheboro, N. C. Clay, Don S. AsheboroDon S. Clay, Raleigh , N. C. Clay, Don S. RaleighNames with prefixes are filed disregarding punctuation and spacing within the surnameRena de la Santosde la Santos, RenaAmee La CroixLa Crois, AmeeDavid M. McArthurMcArthur, David M.Abbreviated names are files as though the names were spelled out.Chas. MalleyMalley, CharlesCharles L. MalleyMalley, Charles L.Professional titles and degrees are placed at the end of the name and enclosed in anizations and Businesses in order they are written American, Red, CrossException: If Owner's name is name of business, then follow name rulesThe T.S. Eliot Company is filed as Eliot, T., S., CompanyHyphenated names are considered as one unitAfter indexing, follow strict alphabetical order, use as many letters as needed to fileNothing comes before somethingNumbers in a name are indexed as though they were spelled outNumeric FilingCross indexing (referencing) is requiredPatient names are indexed as for alpha filingAgency numbering usually runs in order, and a record is kept of which numbers have been assigned.When patient comes to agency, alpha cross index is checked to locate patient's file numberNumbers go in order from small to largeIf zero falls before other numbers, the zero is disregarded when filingMany systems use the same terminal (last) digit for certain shelves or drawers - if so - check the last digit and then put all the same last digits togetherAlphabetic Filing Name ___________________Handout Date ____________________Directions: Index each patient’s name in the space provided. Put the names in alphabetic order in the space provided.Indexed Names Alphabetic Names123456789101112131415Mary ChildersJohanna Q. MillerRev. Frank A. Mathews Sr.Dollar Tree, La Grange, N. C.Francis HaddockDollar Tree, La Grange, Il.Daniel L. BachSouth-West Auto ClubSusan B. Jordan, CPAJerri B. EvansWilliam Morris, Jr.Dollar Tree, La Grange, Ky.Southwest Regional AirportHans BradshawDr. Frank A. Mathews, Jr.Numeric Filing Name ___________________Handout Date ____________________Directions: Place each group of numbers according to the numeric filing system in the space provided. Straight NumericTerminal Numeric12345678910111213141509248-9794009-9802736-9119985-9884755-9835594-9993747-9283790-9976630-9666655-9602836-9183610-9987330-9173660-9771740-92 ................
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