Cracking the Code: A quick reference guide to interpreting patient medical notes
()
About this ebook
Much of this book concentrates on the secondary care environment because this remains the main setting in which healthcare professionals have free and open access to patient medical notes. However, the expanding roles of healthcare professionals in the primary care sector mean that all practitioners need to be able to ‘unlock the code’ of medical terminology and abbreviations. It is hoped that this book will therefore be of use not only to the undergraduate pharmacy students for whom it was originally developed, but also to other healthcare professionals who routinely access patient medical notes.
This new edition has been revised and updated to incorporate measurements of body weight and surface area, capillary blood gases, sepsis screening, common drug serum levels, and changes to the reporting of cardiac troponins.
Contents include:
Section 1: Medical terminology
Section 2: Patient medical notes
Section 3: Investigative procedures
Section 4: Laboratory reports
Section 5: Medical abbreviations
Related to Cracking the Code
Related ebooks
Cracking the Code: A quick reference guide to interpreting patient medical notes Rating: 0 out of 5 stars0 ratingsThe Slim Book of Health Pearls: The Complete Medical Examination Rating: 0 out of 5 stars0 ratingsAll Things Medical Rating: 5 out of 5 stars5/5Systematic Medical Terminology Rating: 0 out of 5 stars0 ratingsThe Essential Guide to Prescription Drugs, Update on Remdesivir Rating: 0 out of 5 stars0 ratingsNumeracy and Clinical Calculations for Nurses, second edition Rating: 1 out of 5 stars1/5Routine Blood Results Explained 3/e: A guide for Nurses & Allied Health Professionals Rating: 3 out of 5 stars3/5Clinical Examination Skills for Healthcare Professionals Rating: 4 out of 5 stars4/5Developing Advanced Assessment Skills: Patients with Long Term Conditions Rating: 0 out of 5 stars0 ratingsVital Signs for Nurses: An Introduction to Clinical Observations Rating: 0 out of 5 stars0 ratingsMedicine Management Skills for Nurses Rating: 0 out of 5 stars0 ratingsEssential Pharmacology For Inpatient Care Rating: 5 out of 5 stars5/5Medical Records Clerk: Passbooks Study Guide Rating: 0 out of 5 stars0 ratingsBasic Training For Careers In Health Care Rating: 0 out of 5 stars0 ratingsMedical Terminology Demystified Rating: 4 out of 5 stars4/5ICD Medical Thesaurus For Medical Coders Rating: 5 out of 5 stars5/5Medical Terminology: A Student Workbook Rating: 1 out of 5 stars1/5Cross-Training: The Medical Assistant Workbook Rating: 0 out of 5 stars0 ratingsSchaum's Outline of Medical Charting: 300 Review Questions + Answers Rating: 0 out of 5 stars0 ratingsMedical Billing & Coding Demystified, 2nd Edition Rating: 4 out of 5 stars4/5Medical Charting Demystified Rating: 2 out of 5 stars2/5The Most Effective Way to Breakdown the Medical Vocabulary - Medical Terminology Easy Guide for Beginners Rating: 0 out of 5 stars0 ratingsMedical Coding ICD-10-PCS: a QuickStudy Laminated Reference Guide Rating: 0 out of 5 stars0 ratingsLove, Chocolates and Medicine Rating: 0 out of 5 stars0 ratingsMedical Billing Rating: 0 out of 5 stars0 ratingsThe Everything Guide To Careers In Health Care: Find the Job That's Right for You Rating: 5 out of 5 stars5/5Medical Coding ICD-10-CM: a QuickStudy Laminated Reference Guide Rating: 0 out of 5 stars0 ratingsMedical Records Specialist: Passbooks Study Guide Rating: 0 out of 5 stars0 ratings
Medical For You
Women With Attention Deficit Disorder: Embrace Your Differences and Transform Your Life Rating: 5 out of 5 stars5/5The Vagina Bible: The Vulva and the Vagina: Separating the Myth from the Medicine Rating: 5 out of 5 stars5/5What Happened to You?: Conversations on Trauma, Resilience, and Healing Rating: 4 out of 5 stars4/5Brain on Fire: My Month of Madness Rating: 4 out of 5 stars4/5Mediterranean Diet Meal Prep Cookbook: Easy And Healthy Recipes You Can Meal Prep For The Week Rating: 5 out of 5 stars5/5The Emperor of All Maladies: A Biography of Cancer Rating: 5 out of 5 stars5/5Adult ADHD: How to Succeed as a Hunter in a Farmer's World Rating: 4 out of 5 stars4/5The People's Hospital: Hope and Peril in American Medicine Rating: 4 out of 5 stars4/5Herbal Healing for Women Rating: 4 out of 5 stars4/5The Diabetes Code: Prevent and Reverse Type 2 Diabetes Naturally Rating: 4 out of 5 stars4/5Gut: The Inside Story of Our Body's Most Underrated Organ (Revised Edition) Rating: 4 out of 5 stars4/5The Lost Book of Simple Herbal Remedies: Discover over 100 herbal Medicine for all kinds of Ailment Inspired By Barbara O'Neill Rating: 0 out of 5 stars0 ratingsThe Song of the Cell: An Exploration of Medicine and the New Human Rating: 4 out of 5 stars4/5Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner Rating: 4 out of 5 stars4/5ATOMIC HABITS:: How to Disagree With Your Brain so You Can Break Bad Habits and End Negative Thinking Rating: 5 out of 5 stars5/5Living Daily With Adult ADD or ADHD: 365 Tips o the Day Rating: 5 out of 5 stars5/5Tight Hip Twisted Core: The Key To Unresolved Pain Rating: 4 out of 5 stars4/5"Cause Unknown": The Epidemic of Sudden Deaths in 2021 & 2022 Rating: 5 out of 5 stars5/5The Art of Dying Well: A Practical Guide to a Good End of Life Rating: 4 out of 5 stars4/5A Letter to Liberals: Censorship and COVID: An Attack on Science and American Ideals Rating: 3 out of 5 stars3/5Hidden Lives: True Stories from People Who Live with Mental Illness Rating: 4 out of 5 stars4/5Holistic Herbal: A Safe and Practical Guide to Making and Using Herbal Remedies Rating: 4 out of 5 stars4/5Rewire Your Brain: Think Your Way to a Better Life Rating: 4 out of 5 stars4/5The Hormone Reset Diet: Heal Your Metabolism to Lose Up to 15 Pounds in 21 Days Rating: 4 out of 5 stars4/5
Reviews for Cracking the Code
0 ratings0 reviews
Book preview
Cracking the Code - Dr Katie Maddock
University
Introduction
In the secondary care setting, health professionals, other than doctors, have been actively involved in extracting and interpreting information found within patient medical notes for many years. Cracking the Code was originally developed as a tool for use by MPharm students to find their way through the seemingly foreign language of medical notes. It has since been expanded to include explanations of how many common medical examinations and tests are performed and how the results of these should be interpreted.
Cracking the Code covers the basics of the contents of patients’ medical notes, from a review of physiological systems to the interpretation of tests and investigations commonly ordered for patients. Common medical terminology used in a review of physiological systems is briefly explained. Commonly encountered investigative procedures are defined and their use explained. Medical laboratory tests are similarly explored.
Much of this book concentrates upon the secondary care environment because this remains the main setting in which healthcare professionals have free and open access to patient medical notes. However the expanding roles of healthcare professionals in the primary care sector, such as pharmacists working within GP practices, and non-medical prescribers in nursing, pharmacy and physiotherapy, mean that all practitioners need to be able to unlock the code. It is hoped that this book will therefore be of use not only to the undergraduate pharmacy students for whom it was originally developed, but also to pre-registration trainees and pharmacists practising in all sectors of the profession, and all other healthcare professionals who access patient medical notes on a routine basis.
This second edition has been updated to incorporate measurements of body weight and surface area, capillary blood gases, sepsis screening, common drug serum levels, and changes to the reporting of cardiac troponins. This book is not designed to be a comprehensive text to be read from cover to cover. Rather, it is a quick reference guide to dip in and out of, as the need arises. Many other, larger, texts are available, which explain in great detail all the areas covered in this book, should a deeper exploration be required.
Katie Maddock, December 2017
Section 1
Medical terminology
In order to interpret a patient’s medical notes accurately and with confidence, it is essential to have a good grasp of medical terminology. Some of the terms that are commonly encountered may appear to be very long and complicated but they are generally built up from smaller ‘building blocks’. Once the longer terms have been broken down into their constituent blocks, the meaning becomes much clearer.
Medical terms have three basic components: the root, which forms the basis of the word; a prefix – any syllables added in front of the root to modify it and a suffix – any syllables added after the root to modify it. Knowledge of the meanings of a few common roots, prefixes and suffixes enables the understanding of the majority of commonly encountered medical terms.
For example:
i.e. a condition resembling underactivity of the parathyroid glands.
Tables 1.1 and 1.2, on page 2, contain some of the common roots, prefixes and suffixes that are encountered in clinical practice.
Table 1.1: Common medical prefixes, suffixes and roots
Table 1.2: Common surgical suffixes
Section 2
Patient medical notes
To be involved effectively in the clinical decision-making process, it is important to be able to understand and utilise the information to be found in the patient medical notes. On occasions it is also necessary for the pharmacist to record their interventions in a patient’s medical notes.
The medical notes are a chronological record of all significant aspects, including drug treatment, of a patient’s care. These are completed for both inpatient stays and for outpatient clinic visits. As a clinical pharmacist you will frequently intervene directly in the care of patients to ensure the safety and efficacy of their treatment. If you do need to intervene in a patient’s drug treatment, there are a number of ways in which you can convey this information to the prescriber(s) concerned.
Face to face with the prescriber
This is much the best way to deal with any concerns you have. The modifications you wish to recommend to the prescriber can be discussed and you will all have the information you require to hand. The prescriber is unlikely to document your intervention in the patient’s medical notes.
Bleeping or phoning the doctor
If the prescriber is not available for a face to face discussion and the intervention you wish to make is urgent, this is the method used for contacting the prescriber. However, it may not be a convenient time for the prescriber to talk to you. Again, it is unlikely that the prescriber will document your intervention in the patient’s medical notes.
Leaving a note on the prescription
This is often used as a method of communication in the hospital environment, particularly if the prescriber is a surgeon, is in theatre and cannot be disturbed. However, such notes are easily lost and if your intervention is not addressed by the prescriber it is difficult to say whether the prescriber saw your note and chose to ignore it, or whether your note was seen at all. Again there is no permanent record of your intervention.
Leaving a message with another member of staff
Your message may not be passed on correctly, if at all. Again there is no permanent record of your intervention.
The following are examples of when you, as a clinical pharmacist, should document your interventions in a patient’s medical notes:
•When you recommend that a drug is initiated or discontinued
•When you have discovered that an adverse drug reaction has occurred
•When you discover that the patient is not, or has not been, compliant with their medication
•When your input has been requested by the medical team
•When a critical change to a dosage regimen has occurred
•When an important recommendation has not been followed
•When your written communication would facilitate