Medical Terminology Used in Communication Between Healthcare Providers Essay Paper
Question
Carlos presented to emergency with a three-week-old shoulder wound. It seems to be black in colour, with a lot of thick yellow discharge and bright red edges. Determine how medical terminology might be used to document this. The wound appears necrotic, with pus and inflammation around the edges. Wound has good epithelialization, purulent pus, and inflammation around the borders. The wound has a serous oozing, a huge black region, and some slight irritation around the edges The wound seems moist, with a crimson border and haemoserous oozing.
Step 1/7
1.Identify the pertinent information about the wound:
Explanation:
Black in color, thick yellow discharge, bright red edges, and 3 weeks old.
Step 2/7
2.Use medical terminology to describe the wound:
Explanation:
“The wound appears necrotic, with pus and inflammation around the edges.”
Step 3/7
Consider the degree of healing:
Explanation:
involves using medical terminology to document the characteristics of the wound, including its color, discharge, and inflammation. This documentation is important for accurately describing the wound and informing treatment decisions. It also allows for clear communication between healthcare providers and continuity of care for the patient.
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Step 4/7
Note the type of discharge:
Explanation:
involves organizing and presenting the documented information using appropriate medical terminology, abbreviations, and symbols. The information should be accurate, concise, and clear, with a focus on the essential details. It should also be communicated effectively to ensure that other healthcare professionals can easily understand the condition of the wound and provide appropriate treatment.
Step 5/7
Observe the border of the wound:
Explanation:
“inflammation around the borders” or “slight irritation around the edges”.
Step 6/7
Describe any additional characteristics such as color, size or exudate:
Explanation:
“The wound has a serous oozing, a huge black region” or “The wound seems moist, with a crimson border and haemoserous oozing.”
Step 7/7
Document the information clearly and accurately in the medical record, using appropriate medical terminology.
Final answer
The medical terminology used to document Carlos’s three-week-old shoulder wound is “necrotic with pus and inflammation around the edges” or “having good epithelialization, purulent pus, and inflammation around the borders.” It is important to use specific medical terminology when documenting wounds to ensure clear and concise communication between healthcare providers. Medical Terminology Used in Communication Between Healthcare Providers Essay Paper