Assessment Instructions:
This assessment requires students to use accurate medical terminology, clinical abbreviations and acronyms using problem solving skills both verbally and documenting relating to each of the following:
- Neoplasms.
- pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities.
- symptoms, signs and abnormal clinical and laboratory findings.
- injury, poisoning and causes of morbidity and mortality.
Students Instructions-
Students will be given access to
- real – life patient healthcare records – Appendix 1 and 2
- organisational policies and procedures – Appendix 3
Students will be given individual times to be assessed on campus. The completed task is to be uploaded to Blackboard in the assessment 2B folder.
Refer to Appendix 1 in Blackboard under assessments – Richard Burton Case Study- healthcare records.
Theatre Admission Richard Burton – Right Hemicolectomy
The above patient is being admitted to theatre to remove a cancerous tumour in the right side of the colon.
Q1 Analysing Richard`s theatre admission documentation and case notes (Appendix 1) regarding his colon cancer diagnosis – Interpret two medical terms identifying and dividing into constituent (prefix, word root & suffix) – documenting below and verbally to your assessor.
Q2 Analysing Richard`s theatre admission documentation (Appendix 1) – Build two medical terms using constituent parts – documenting below and verbally to your assessor regarding the tumour.
Q3 Analysing Richard`s theatre admission documentation (Appendix 1) – Interpret two clinical abbreviations acronyms in clinical documentation – documenting below and verbally to your assessor.
Q4 Analysing Richard`s theatre admission documentation (Appendix 1) – Interpret two different medical terminology to identify sources and types of information in patient health care records – documenting below and verbally to your assessor.
Q5 Analysing Richard`s theatre admission documentation (Appendix 1) – in the area below, apply an understanding of two different medical terms to determine reason for episode of care – documenting in area below and verbally to your assessor.
Q6. Analysing Richard`s theatre admission documentation (Appendix 1) – Apply an understanding of two different medical terms to determine surgery and intervention performed, documenting in area below and verbally to your assessor.
Q7. Using accurate (a) medical terminology, (b) clinical abbreviations, and (c) acronyms -Document below and verbally to your assessor one abnormal clinical finding and one laboratory finding relating to the above case study of Richard Burton.
Q8. Using accurate medical terminology, clinical abbreviations, and acronyms in at least one oral and one written communication, document below and verbally to your assessor for (a) injury, (b) poisoning and (c) cause of morbidity and (d) mortality which may result in a complication of Richard`s surgery e.g.- sepsis.
Refer to Appendix 1 in Blackboard under assessments – Pamela Green Case Study- healthcare records.
Theatre Admission Pamela Green – Planned Caesarean Section
Pamela Green is a 29-year-old pregnant woman who is 38/40 gestation. Pamela has been on bedrest in the antenatal ward for one week, admitted due to hypertension, proteinuria and reduced foetal movements.
Blood tests have revealed a congenital abnormality with the baby.
A planned Caesarean Section is planned later today
Q9. Using accurate (a) medical terminology, (b) clinical abbreviations, and (c) acronyms in at least one oral and one written communication, document below and verbally to your assessor for pregnancy.
Q10. Using accurate (a) medical terminology, (b) clinical abbreviations, and (c) acronyms in at least one oral and one written communication document below and verbally to your assessor for childbirth.
Q11. Using accurate (a) medical terminology, (b) clinical abbreviations, and (c) acronyms in at least one oral and one written communication document below and verbally to your assessor- for puerperium conditions originating in the perinatal period including (1) congenital malformations, (2) deformations and (3) chromosomal abnormalities.
- Congenital malformations
- Congenital deformations
- Chromosomal abnormalities