reports
- This assignment has several parts to it:
- Write a 1000-word essay summarizing each of the Four reports below, how they will be used in your chosen career, is there information missing from the reports, proposed improvements and better ways this information could be conveyed. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least one (1) citation in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount. Review the rubric criteria for this assignment.
- Rewriting Four Reports – Each report task requires a minimum of 300 words. Separate each report with the proper heading and follow the proper formatting for each.
- Review the Sample Radiology Report located on page 102, Figure 4-2 Sample Radiology Report of the text “Grammar & writing skills for the health professional (3rd Ed.)”, copy the entire format and rewrite the; Primary Diagnosis, Clinical Information, and Impression sections of the report into common language that the normal patient would understand. Make sure any medical terminology is explained.
- Review the Sample Pathology Report located on page 103, Figure 4-3 Sample Pathology Report of the text “Grammar & writing skills for the health professional (3rd Ed.)”, copy the entire format and rewrite the; Preoperative and Postoperative Diagnosis, Gross Description, and Microscopic Diagnosis sections of the report into common language that the normal patient would understand. Make sure any medical terminology is explained.
- Review the Sample Discharge Report located on page 105, Figure 4-4 Sample Discharge Summary of the text “Grammar & writing skills for the health professional (3rd Ed.)”. Use the seven (7) bulleted items on page 104 under “Discharge” summary, write short paragraphs using the non-medical terms that you would use to explain the information on the Discharge Summary Report to the patient or their representative. Not every one of the seven points may be needed.
- Review the Sample Operative Report located on page 106, Figure 4-5 Sample Operative Report of the text “Grammar & writing skills for the health professional (3rd Ed.)”. Copy the entire format and rewrite the; Preoperative and Postoperative Diagnosis, Operative Procedure, Anesthesia, and Description sections of the report into common language that the normal patient would understand. Make sure any medical terminology is explained
Length: 1000-word essay and four reports (1200 words).
Structure: Each report has its own format. Be sure to follow the proper format for each. Include a title page and reference page in APA style. These do not count towards the minimal word amount for this assignment.
Format: Save each of your assignments as a separate Microsoft Word document (.doc or .docx).
File name: Name your saved file according to your first initial, last name, and the assignment number (for example,
SAMPLE ASSIGNMENT ANSWER
Description of Radiology, Operative, Pathology, and Discharge Reports
Apart from providing care, healthcare professionals are also needed to document care activities. One of the reports that can be created by healthcare professionals is the discharge summary report. The report is significant when a patient is discharged from the hospital. Other documentations include pathology, radiology, and operative reports. The purpose of this essay is to discuss discharge summaries, pathology, radiology, and operative reports and how they will be used in my chosen career.
Radiology Report
A radiology report is the official documentation of clinical images containing imaging tests and interpretations (Alarifi et al., 2021). According to Alarifi et al. (2021), the main purpose of a radiology report is to present the findings of the imaging tests taken as recommended by a physician or a doctor. The report shows the results of imaging tests such as CT scans, MRIs, or X-rays. Alarifi et al. (2021) noted that a radiology report describes the findings of tests such as CT scans and other imaging procedures. The report includes information about the test and how it was conducted. The report also shows a brief medical history of the patient having the test, including any presenting symptoms (Alarifi et al., 2021). it also includes the reason why the test was ordered and who ordered it. The report is often needed by doctors to make the correct diagnosis and prescribe the right medication. The report has four main parts including a description of findings, radiographic diagnosis, differential diagnosis, and recommendations (Alarifi et al., 2021). The radiology report below can be improved by including differential diagnosis and the recommendation sections since these parts are mission from the report.
Operative Report
Another important piece of documentation in my career is the operative report. An operative report is a documentation in a patient’s medical records that records the details of the surgery. It is created immediately after a surgical procedure and transcribed into the patient’s record later. The report is often created by the surgeon responsible for the surgery (Oberg & Villemaire, 2017). The operative report will be used in my career as a nurse to describe a surgical procedure. The surgeon in charge of the surgery will use an operative report to explain all the surgical procedures that were undertaken. The record will also be used in my career to support the medical necessity for the surgical procedure. The report will why the surgery was needed. Lastly, the report will be used to reveal whether the surgery was successful or a failure and whether adverse effects occurred if any (Oberg & Villemaire, 2017). The report is used to assess the billing and medical-legal issues and the quality of surgical procedures.
Various elements are missing from the report which could be included to improve the document. One of the mission elements that should be included in the report is the estimated blood loss. The surgeon should have explained the estimated blood that was lost during the surgical procedure. The second element is intra-operative complications. The surgeon who wrote the operative report below did not mention whether there was any complication or not during the procedure. Lastly, the surgeon should have named the type of surgery performed. Lastly, the surgeon did not mention the lead and assisting physicians during the surgery. Oberg and Villemaire (2017) noted that the names of the primary surgeon and assistants should be part of the report. Overall, the operative report included most of the information that need to be in such a document.
Pathology Report
A pathology report is medical documentation about a body organ, piece of tissue, or blood that can be removed from a patient’s body and taken to a pathologist for further examination (Ryu et al., 2020). The pathologist analyzes the specimen and then writes the report for a healthcare professional who performed the procedure or ordered the report. The purpose of the report is to provide healthcare providers with information to determine a treatment plan or diagnosis for a specific disease or health condition. The report is often used by oncologists to determine whether a patient has cancer and assess the prognosis of the disease.
The pathology report is also used by oncology surgeons to determine whether the whole cancerous cells have been removed during a surgical procedure (Ryu et al., 2020). Elements of the report include the patient’s name, date and type of procedure used to obtain the specimen, current clinical diagnosis and medical history, a general description of the specimen sent to the lab, and the findings (Ryu et al., 2020). The report below has most elements highlighted by Ryu et al. (2020). However, it can be improved by including current clinical diagnoses and medical history.
Discharge Report
Another report is a discharge summary. Wembridge and Rashed (2022) noted that a discharge summary is a report created by a healthcare professional after a patient has concluded a series of treatment or their stay at the hospital. The authors argued that a discharge summary is a link between hospital care professionals and people outside the hospital who will care for the patient after being discharged. The main purpose of the report is to summarize the progress of the patient toward treatment goals, their health status at discharge, and plans for self-management (Wembridge & Rashed, 2022). It also includes any medications a patient should be prescribed to take while at home and any follow-up care. A discharge report should include six main components.
The first component is the reason for hospitalization and the primary presenting condition at the time of admission. The second component is the significant findings based on clinical experience, research, and laboratory findings. The third element is the treatments and procedures provided. The other three elements include the patient’s discharge condition, the attending physician’s signature, and patient and family instructions as needed (Wembridge & Rashed, 2022). The discharge report below has included almost all the elements of a discharge summary report. However, the report could have been improved by clearly stating the patient’s current condition.
Conclusion
The four reports are vital in my future career. A radiology report will be used to present the findings of the imaging tests taken as recommended by a physician or a doctor. An operative report will be used to describe a surgical procedure. The pathology report will be used to provide healthcare providers with information to determine a treatment plan or diagnosis for a specific disease or health condition. A discharge report will be used to summarize the progress of the patient toward treatment goals, their health status at discharge, and plans for self-management.
References
Alarifi, M., Patrick, T., Jabour, A., Wu, M., & Luo, J. (2021). Understanding patient needs and gaps in radiology reports through online discussion forum analysis. Insights into Imaging, 12(1), 1-9.
Wembridge, P., & Rashed, S. (2022). Discharge summary medication list accuracy across five metropolitan hospitals: A retrospective medical record audit. Australian Health Review, 46(3), 338-345.
Oberg, D., & Villemaire, L. (2017). Grammar and Writing Skills for the Health Professional (3rd ed.). Cengage Learning US. https://bookshelf.vitalsource.com/books/9781337515702
Ryu, B., Yoon, E., Kim, S., Lee, S., Baek, H., Yi, S., & Yoo, S. (2020). Transformation of pathology reports into the common data model with oncology module: Use case for colon cancer. Journal of Medical Internet Research, 22(12), e18526.
Radiology, Operative, Pathology, and Discharge Reports
Radiology Report
Patient Name: Marietta Mosley
Hospital No: 11446
X-ray No: 98-2801
Admitting Physician: John Youngblood, M.D.
Procedure: Left hip x-ray
Date: 08/05/2023
PRIMARY DIAGNOSIS: Broken left hip.
CLINICAL INFORMATION: Feeling pain on the left hip. Has no known allergies.
An orthopedic device is seen fixing the damaged left femoral neck. An orthopedic device is a special equipment designed to preserve or correct and restore the function of the damaged human skeletal system, associated structures and its articulations. The femoral neck is part of the bone that links the shaft with the head. The patient did not present old x-ray pictures which were taken when the patient’s left femoral neck was broken for comparison with the current x-ray results. The left femoral neck appears to heal and align with other bone structures within the region. There is a thin area along the side of the femoral neck, approximately at the lesser trochanter level which is observed in the back and lower part of the femur neck base in which an x-ray beam can pass through. An x-ray beam is a visible light from the x-ray machine. This observation shows that the area is broken and there is no way to tell when the fracture occurred. There is thinking of the bone below the cartilage in the joints at the fractured site. There is also moderate angulation and offset at the site. Angulation is a type of fracture displacement where the bone’s normal axis is tampered with such that the portion of the bone points off in a different direction. It is also known as dorsal or palmar.
Fairly healing of the unstable fractures is observed laterally along the femoral shaft.
IMPRESSION: The x-ray does not show any significant displacement at the femoral neck.
Failure of a broken bone to mend and heal after a long period transversely through the shaft of the femur at about the level of the lesser trochanter.
Neil Nofsiager, M.D
NNxx
D: 08/05/2023
T: 08/05/2023
Pathology Report
Patient Name: Sumio Yukimura
Hospital No: 11449
Pathology Report No: 98-S-942
Admitting Physician: Donna Yates, M.D
Preoperative Diagnosis (Diagnosis before the operation): Cholelithiasis. Cholelithiasis also known as gallstones are hardened deposits of digestive fluid that form in one’s gallbladder.
Postoperative Diagnosis (Diagnosis after the operation): Cholelithiasis. Cholelithiasis also known as gallstones are hardened deposits of digestive fluid that form in one’s gallbladder.
Specimen Submited: Gallbladder and stone. A specimen is a small amount of tissue or body part such as blood, urine, taken for testing. The admitting M.D collected tissues of gallbladder and stone from the patient’s gallbladder and sent it for testing to the pathologist.
Date Received: 06/05/2023
Date Reported: 06/06/2023
GROSS DECRIPTION: Specimen were received in a container labeled” gallbladder.” The gallbladder in the specimen measured 9 cm long and 2 cm in average diameter. The outer lining of the gallbladder shows diffuse fibrous adhesion. Fibrous adhesion is also known as muscle adhesion. Fibrous adhesion is a medical condition that occurs in the soft adjacent tissue stick to collagen fibers. The wall is thickened and bleeds excessively. There is a single hardened deposit measuring 2 cm in diameter within the lumen of the gallbladder and the mucosa is eroded. The hardened deposit is known as stone. Representative sections are seen in one cassette.
GROSS DIAGNOSIS: The patient has gallstone, a medical condition leading to hardening of the walls of the gallbladder.
KMxx
D: 06/05/2023
T: 06/05/2023
MICROSCOPIC DIAGNOSIS: The patient’s gallbladder has a stone which has hardened its walls and it is bleeding.
Robert Thomson M.D
RT: xx
D: 06/06/2023
T: 06/06/2023
Discharge Report
The name of the patient is Joyce Mabry. She was admitted on 02/18/2023 and discharged on 02/24/2023. Tom Moore, M.D., Hematology was her consultant. The procedure conducted was elective splenectomy. Elective splenectomy is a treatment performed after conservative treatment in patients with autoimmune disorders has failed. There were no complications during the procedure.
She was diagnosed with elective splenectomy for idiopathic thrombocytopenic purpura and systemic lupus erythematosus during admission. Idiopathic thrombocytopenic purpura is a blood disorder that causes abnormal reduction of platelet levels in the blood. Systemic lupus erythematosus is an autoimmune disorder where the tissues are attacked by their immune system.
The patient is a 21-year-old white woman diagnosed with thrombocytopenic purpura and systemic lupus erythematosus. She presented with bruising. She was treated with steroids, prednisone 20 mg. However, her platelets are still low. She was admitted for elective splenectomy.
Various tests were performed on admission. Chest x-ray showed normal results. Electrocardiogram also showed normal results. All other laboratory tests showed normal results, apart from platelet tests which were low.
A splenectomy operation was performed on the patient on February 19. No complication was witnessed during the operation and with wound healing. Her platelet counts for three days consecutively after the operation. She received a transfusion of 10 units of platelets during the operation and 10 units after the surgical procedure. Her platelet level rose to 77,000 fourth day after the operation which was significantly high. She was discharged and asked to come to my office for a follow-up. She will also be seen by Dr. Moore for follow-up care.
She is prescribed the following medications to take at home. She is prescribed Prednisone 20 mg once a day. She is also prescribed Percocet 1 to 2 by mouth every 4 hours when needed for pain. The patient has also been prescribed multivitamins, 1 every morning and once a day.
Operative Report
Patient Name: Kathy Sullivan
Hospital No: 11525
Date of Surgery: 06/25/2023
Admitting Physician: Taylor Withers, M.D.
Surgeons: Sang Lee, M.D., Taylor Withers, M.D.
Preoperative (before surgical procedure) Diagnosis: Unable to hold urine because the urethra and bladder into the virginal part bulge out from the normal place. In other words, the bladder and urethra have protruded.
Postoperative (after surgical procedure) Diagnosis: Unable to hold urine because the urethra and bladder into the virginal part bulge out from the normal place.
Operative Procedure: Total abdominal hysterectomy with Marshall-Marchetti correction. An abdominal hysterectomy is a surgical operation where the uterus of a patient is removed through an incision in the lower abdomen. The Marshall-Marchetti-Krantz is a surgical procedure performed to help stress incontinence, a bladder control problem.
Anesthesia (the use of medicine to prevent pain during surgical procedures): General endotracheal. General endotracheal is giving a patient anesthesia and then placing a flexible plastic tube into their trachea from their mouth to help them breathe.
DESCRIPTION: Dr. Withers performed an abdominal hysterectomy and closed the peritoneum and then turned the procedure to me. Peritoneum is a membrane that supports abdominal organs.
At this time, I entered the abdominal wall’s concave depression layer around the bladder was entered. The parts (frontal part of the urethra and bladder) that pass urine were cut and divided free using a sharp and blunt cut. Surgical instruments were used to compress any bleeding vessel and an electric current was used to burn it. A bone rasp was used to take the outer covering of the bine and made it rough. Urethra was then attached to a joint that connects two pubic bones by placing two No. I cargut sutures on both sides of the urethra and one in the neck of the bladder. Cargut suture is a surgical suture that degrades naturally with the body’s enzymes. Bleeding was well controlled. There was no much blood loss. I then turned the procedure for closure to Dr. Withers.
Sang Lee, M.D.
SLxx
D: 06/25/2023
T: 06/25/2023
Jermaine Byrant
Nicole Johnson
OVER
RATING
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