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