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It is very important to verify word/words. An
incorrect word could seriously jeopardize a
patient’s safety.
Proofreading and editing are different skills, yet
go hand in hand in creating medical
documents. We will correct spelling, grammar,
and punctuation and also ensure the text
matches the content of the document.
Developing basic proofreading and editing
skills for revision of written text is necessary to
create accurate written documentation.
One type of error at a time. If you focus on one type of
error at a time, such as spelling or punctuation, you will
find it easier to maintain accuracy. Each type of error
has a different visual and mental process. In time you
will be able to combine these skills and perform them as
you are transcribing, all at the same time. Is the report
formatted correctly? Placement of headings, text size,
and paragraphs need to be checked and consistency
maintained in the appearance of the document.
Read every word out loud. When you read aloud, you
will find that you recognize how the words sound
together. When we read silently, we tend to read too
quickly, and it is very easy to skip or miss errors, or
make unnecessary corrections. Does the content make
sense? Do the facts match the complaint? Be sure to
document a discrepancy in the interpretation of the
content or anything else that may cause confusion.
Below are some proofreading exercises. See if you can
spot the 5 errors in each paragraph.
Earlier today, the patient underwent a lumber
laminectomy with discectomy and she is currently
voicing discomfort and pain at the surgical sight.
Earlier today the patient underwent a lumbar
laminectomy with diskectomy, and she is currently
voicing discomfort and pain at the surgical site.
Earlier today, the patient underwent a lumber
laminectomy with discectomy and she is
currently voicing discomfort and pain at the
surgical sight.
On examination patients vital signs showed a
blood pressure of 108/06, temperature 36.4 pulse
54, respiritions 18.
On examination her lungs sounded clear
bilaterally.
Heart: Regular rate and rhythm, S1:S2.
Abdominal examination: Benign.
On examination patient's vital signs showed a blood
pressure of 108/60, temperature 36.4, pulse 54,
respirations 18.
On examination her lungs sounded clear bilaterally.
Heart: Regular rate and rhythm, S1, S2.
Abdominal examination: Benign.
On examination patients vital signs showed a blood
pressure of 108/06, temperature 36.4 pulse 54, respiritions
18.
On examination her lungs sounded clear bilaterally.
Heart: Regular rate and rhythm, S1:S2.
Abdominal examination: Benign.
The chinchilla are a very soicial animal, and they
like to spend time with their families, but they do
not like to be picked up or held They sometimes
like to be scartched behind there ears.
The chinchilla is a very social animal, and they
like to spend time with their families, but they do
not like to be picked up or held. They sometimes
like to be scratched behind their ears.
The chinchilla are a very soicial animal, and they
like to spend time with their families, but they do
not like to be picked up or held They sometimes
like to be scartched behind there ears.
The perparation was excellent. We advanced
into the sigmoid, there were multiple diverticular
openings an tortuosity of the bowl with looping.
We corrected several loops. Then we had to give
her another dose of sedation and finally a 3rd
dose, and we ended up with 1.5 of Versed and
75 mg of fentanyl.
The preparation was excellent. We advanced
into the sigmoid. There were multiple
diverticular openings and tortuosity of the bowel
with looping. We corrected several loops. Then
we had to give her another dose of sedation
and finally a 3rd dose, and we ended up with
1.5 of Versed and 75 mg of fentanyl.
The perparation was excellent. We advanced
into the sigmoid, there were multiple diverticular
openings an tortuosity of the bowl with looping.
We corrected several loops. Then we had to
give her another dose of sedation and finally a
3rd doses, and we ended up with 1.5 of Versed
and 75 mg of fentanyl.
DISCHARGE DIAGNOSIS
1. Upper GI bleeding.
2. Anemia due to gastrintestinal bleeding
3 Duodenal ulcer with bleeding.
4. Gastric ulterations from nonsteroidal
antiinflammatory agent use.
DISCHARGE DIAGNOSES
1. Upper gastrointestinal bleeding.
2. Anemia due to gastrointestinal bleeding.
3. Duodenal ulcer with bleeding.
4. Gastric ulcerations from nonsteroidal
antiinflammatory agent use.
DISCHARGE DIAGNOSIS
1. Upper GI bleeding.
2. Anemia due to gastrintestinal bleeding
3 Duodenal ulcer with bleding.
4. Gastric ulterations from nonsteroidal
antiinflammatory agent use.
CONDITON ON DISCHARGE
Patient has not had any active bleding. She is
doing well. She hasn’t had any abdominal pain.
She has not hda any nausea vomiting. She has
not felt dizzy. She is doing well. No problems
noted at this time.
CONDITION ON DISCHARGE
Patient has not had any active bleeding. She is
doing well. She has not had any abdominal
pain. She has not had any nausea, vomiting.
She has not felt dizzy. She is doing well. No
problems noted at this time.
CONDITON ON DISCHARGE
Patient has not had any active bleding. She is
doing well. She hasn’t had any abdominal pain.
She has not hda any nausea vomiting. She has
not felt dizzy. She is doing well. No problems
noted at this time.
She’ll be going home on Prevacid, and we will
followup symptomatically with a CBC in a week.
I an going to try the nortriptyline 25 mg po q.d.
to see if the headache would be better and neck
pain would be better.
She will be going home on Prevacid, and we will
follow up symptomatically with a CBC in a week.
I am going to try the nortriptyline 25 mg p.o. daily
to see if the headache would be better and neck
pain would be better.
She’ll be going home on Prevacid, and we will
followup symptomatically with a CBC in a week. I
an going to try the nortriptyline 25 mg po q.d. to
see if the headache would be better and neck
pain would be better.
So remember, always proofread your report
carefully before submitting it. Patient safety
depends on it!
I hope you enjoyed this webinar that I, Lias
Thompson, put together. OOPs Lisa lol
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