HCM 205 Final Project Template
A Day in the Life of a Medical Scribe
Complete this template using Patient Record One , , and Patient Record Two Patient Record
Three. Then, submit the completed template to your instructor for grading. Be sure to
include files of your recordings of the pronunciation of medical terms, using a tool such as
Vocaroo. You paste the links or files directly this can in document. For support using
Vocaroo, refer the document. to Vocaroo Tutorial
Section Documenting Patient Information I:
Complete the table below by building medical terms that correspond with the numbered
phrases the Progress Notes section of Patient in Record One. Be sure to use the appropriate
word parts build the to terms. Also include the phonetic spelling for each term in the table.
Place the recording of your pronunciation of the medical terms here:
Section Reviewing Records for Accuracy II:
Complete the table below by listing the incorrectly spelled medical terms from Patient
Record Two, and provide the accurate spelling.
Built Medical Terminology
Phonetic Spelling
1
Pyelonephritis
ˌpīəˌlōnəˈfrīdəs
2
Dehydration
dēˌhīˈdrāSH(ə)n
3
Nephrolithiasis
nef-rō-li-ˈthī-ə-səs
4
Seroculture
se″ro-kul´chur
5
Genitourinary Infection
ˌjenidōˈyo
orəˌnerē inˈfekSH(ə)n
6
Pyrexia
pīˈreksēə
7
Tympanic
timˈpanik
8
Dermis
ˈdərməs
9
Abscess
ˈabˌses
10
Pyelography
pī-ə-ˈläg-rə-fē
Incorrectly Spelled Medical Terms
Accurate Spelling
1
Complant
Complaint
2
Chess Discomfort
Chest Discomfort
3
Nitroglycerine
Nitroglycerin
4
Mycocardial
Myocardial
e e
e e e e
Review the subjective, objective, assessment, and plan (SOAP) note in Patient Record Two
to ensure the interpretation of the notes is accurate, based on the patient’s diagnosis and
results of relevant vitals. complete this review, address the To following:
1. Identify inaccuracies of interpretation the SOAP note, and in explain why these
elements are inaccurate.
The wording of certain sentences do not make sense. a little es “He is bit vague where as to
his chest really should be phrased is” “where is”. his chest pain really It is stated that he
was preparing breakfast the bathroom in which is not right. Patient history refers to the text
but lack any actually listing.
2. Explain how revise the SOAP note to to include the correct medical terms and an
accurate documentation of the patient’s diagnosis:
CHIEF COMPLAINT: 72yr old male with angina
HISTORY PRESENT ILLNESS: Patient suffers from angina and frequently takes OF
Nitroglycerin. According his wife, the episodes have increased along with weight gain to
over the winter. This coupled with little is to not physical exercise. Patient also is
experiencing indigestion with uncertainty cardiac or gastrointestinal related. as to if it is
There also history of myocardial farction with treatment by is in catheterization.
PAST MEDICAL HISTORY: Patient had myocardial infarction in 1981
SOCIAL HISTORY & FAMILY HISTORY: Patient married, does not smoke though he is
used to, does not drink, and no previous diseases in the family
