Nancy Jackson-Davis Full Medical Record DQ
Nancy Jackson-Davis Full Medical Record DQ
In this course project assignment, you are presented with a full medical chart for one individual patient. An entire medical record can be very lengthy and challenging to navigate. You will see some familiar sections of a medical record that were covered in Modules 02-05, as well as various other notes and details pertaining to this patient.
You will be exploring the medical terminology used in this medical record and will be asked to find information and interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the full medical record for the one patient: Nancy Jackson-Davis Full Medical Record
- Download, complete, and submit the document below. This document contains questions you will answer regarding the medical record for the patient.
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- Each question is associated with the medical record provided. Refer to this when answering each question. Please type your answer in the “Click here to enter text” space.
Patient – Nancy Jackson-Davis
- Identify and describe the first diagnosis listed under the Chronic Diagnoses section.
Click here to enter text. - Which medication was prescribed for Nancy’s diagnosis of gastroesophageal reflux disease?
Click here to enter text. - Which anatomical organ did Nancy have removed in 1992?
Click here to enter text. - Which of Nancy’s relatives experienced a condition that could be described as “a protrusion of an abdominal organ”?
Click here to enter text. - Around 1996, Nancy received a vaccination that will protect which of her digestive organs?
Click here to enter text. - In Nancy’s physical examination, which two abdominal organs are explicitly noted?
Click here to enter text. - On her March 6th visit, Nancy received a prescription for a new medication. As noted in her medical chart, what is the medical abbreviation of how many times per day should she take this medication?
Click here to enter text. - On her April 8 office visit, Nancy reports a new symptom involving blood. Identify the medical term and define it.
Click here to enter text. - Nancy’s physician notes her pain complaints as “epigastric.” What does this mean?
Click here to enter text. - Throughout Nancy’s medical chart, a hernia is mentioned. What type of hernia does she have? Describe where it is and which anatomical structures are involved.
Click here to enter text. - On April 8, Nancy’s physician orders an imaging procedure. Name and define this procedure.
Click here to enter text. - On April 8, which lab test is ordered with the order number 1704Q0Y0? If this test were positive, it would mean blood is present in the _____.
Click here to enter text. - According to Nancy’s imaging report, which of the 3 anatomical regions of the small intestine was explored?
Click here to enter text. - In Nancy’s imaging report, what does the abbreviation LES stand for?
Click here to enter text. - Nancy’s imaging report notes a new finding that is not mentioned anywhere else in her medical chart. What is it?
Click here to enter text.
Nancy Jackson-Davis Full Medical Record DQ References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
- Click here to enter text.
You will also likely need to use other course materials or resources to answer all of this assignment’s questions. If you used other references, cite them here:
- Click here to enter text.
*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa Select “References” on the left-hand panel and choose the type of reference you used.
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