Description
Translate into common terms the medical terms contained in a progress note for a patient with a skin condition. Spell all medical and common terms correctly on the provided template.
Introduction
In this first assessment, you will begin your exploration of the structure of medical terminology. The first step is to review how to build a medical term. Then you will examine the skin and musculoskeletal systems; in particular, we will focus on the diagnosis and treatment of the integumentary, or skin system. The skin is the largest organ of the body with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold. Your suggested resources address the three layers of skin, skin conditions, diseases, treatment, and diagnostic studies.
In the assessment, you will review a progress note. This is a common document found in a health care record in doctors’ offices and hospitals. You will then translate the medical terms in the progress note into common terms.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
Identify medical terms related to general structures and functions of the human body correctly.
Translate medical terms related to general structures and functions of the human body into common terms correctly.
Competency 3: Use medical terminology and abbreviations related to body systems.
Identify medical terms related to body systems correctly.
Translate medical terms related to body systems into common terms correctly.
Competency 6: Spell and pronounce basic medical terms.
Spell medical and common terms correctly.
Competency 7: Communicate in a professional manner.
Provide citations and references in APA style.
Instructions
Review the progress note below, including the subjective and objective notations. Next, download the ATTACHED Skin Progress Note Template [DOCX] and complete all of the following on the template:
Select 15 medical terms from the progress note.
Translate the 15 selected medical terms into commonly used terms.
Spell the 15 medical and common terms correctly.
Cite in correct APA style the references you used to perform your translation. Click Evidence and APA for additional guidance on how to ensure your citations and references conform to APA guidelines.
Skin Progress Note
Subjective: The patient is a 49-year-old female who comes in with the complaint of having bumps on her arms. She states some of the bumps have been there a long time. Recently the bumps have been increasing in number and size. She was last seen about two years ago for eczema, at which time she did not have these bumps. The bumps are not itchy or painful.
Objective: Very pleasant, alert, and oriented x3 female in no apparent distress. A full integumentary exam of the upper extremities was performed today. The left radial aspect demonstrated erythematous macules. The right ulnar aspect demonstrated actinic keratosis. Bilateral hands appeared dry with linear excoriation and fissuring of her fingertips. Bilateral upper arms demonstrated superficial and deep masses. Deep subcutaneous masses are mobile and may represent lipomas. Superficial masses appear to be sebaceous cysts.
Assessment and Plan:
Actinic keratosis of the right ulnar aspect was treated with liquid nitrogen.
Possible lipomas: Schedule surgical biopsy of larger masses.
Sebaceous cysts: Punch biopsy performed today; await pathology report. Apply Neosporin to biopsy site.
Continue Cortisone 10 intensive cream for eczema.
Additional Requirements
Format: Ensure you complete all columns on the Skin Progress Note Template.
Scoring Guide: Be sure to read the ATTACHED scoring guide for this assessment, so you understand how your faculty members will evaluate your work.
Unformatted Attachment Preview
12/15/23, 11:01 PM
Progress Note: The Skin Scoring Guide
Progress Note: The Skin Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Identify medical
terms related to
general structures
and functions of the
human body
correctly.
Does not identify
medical terms related
to general structures
and functions of the
human body correctly.
Attempts to identify
medical terms related
to general structures
and functions of the
human body correctly;
however, omissions
and/or errors exist.
Identifies most
medical terms
related to general
structures and
functions of the
human body
correctly.
Identifies all medical
terms related to
general structures and
functions of the human
body, without errors.
Translate medical
terms related to
general structures
and functions of the
human body into
common terms
correctly.
Does not translate
medical terms related
to general structures
and functions of the
human body into
common terms
correctly.
Attempts to translate
medical terms related
to general structures
and functions of the
human body into
common terms;
however, omissions
and/or errors exist.
Translates most
medical terms
related to general
structures and
functions of the
human body into
common terms
correctly.
Translates all medical
terms related to
general structures and
functions of the human
body into common
terms, without errors.
Identify medical
terms related to
body systems
correctly.
Does not identify
medical terms related
to body systems
correctly.
Attempts to identify
medical terms related
to body systems
correctly; however,
omissions and/or
errors exist.
Identifies most
medical terms
related to body
systems correctly.
Identifies all medical
terms related to body
systems, without
errors.
Translate medical
terms related to
body systems into
common terms
correctly.
Does not translate
medical terms related
to body systems into
common terms
correctly.
Attempts to translate
medical terms related
to body systems into
common terms;
however, omissions
and/or errors exist.
Translates most
medical terms
related to body
systems into
common terms
correctly.
Translates all medical
terms related to body
systems into common
terms, without errors.
Spell medical and
common terms
correctly.
Does not spell at least Spells at least 5
5 medical and common medical and common
terms correctly.
terms correctly.
Spells at least 10
medical and
common terms
correctly.
Spells at least 15
medical and common
terms correctly.
Provide citations
and references in
APA style.
Does not provide
citations and
references in APA
style.
Provides most
citations and
references in APA
style.
Provides all citations
and references in APA
style, without errors.
Attempts to provide
citations and
references in APA
style; however,
omissions and/or
errors exist.
https://a21371-2022794.cluster223.canvas-user-content.com/courses/21371~12809/files/21371~2022794/course files/Scoring Guides/u01a1_scoring…
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Skin Progress Note Template
Number
Medical Term
Example Gastritis
1
Example Esophagogastroduodenoscopy
2
Common Term
Inflammation or infection of the stomach
A procedure used to examine the throat,
stomach, and small intestine through a
scope
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
References in APA Format
1
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