Question

The Family Practitioner

Answer the following items

1. Interpret this scenario into common language. Explain all abbreviation.
2. Explain why professional coder specialists need to understand medical terminology
3. What types of documents would you see in the medical record for a family practitioner office

Scenario:

The Pt came in to see his MD. The MD consulted with the RN. The RN measured the patient’s BP and R. The results of the CBC, TSA, and BUN taken last week were discussed. MD has RN run an EKG. Dx: BPH. Rx: Avodart 0.5mg PO a.c. once per day. Patient to return in 3 months or prn.

Answer 1

The patient visits his MD (Doctor of Medicine). The Doctor examined the patient along with the RN (Registered Nurse). The Registered Nurse checked the patient's vitals such as BP (Blood Pressure) and his R (Respiration). The results of the blood tests for CBC (Complete Blood Count) ,TSA (Tumor-Specific Antigen) and BUN (Blood Urea Nitrogen) - that were taken last week were discussed with the patient. The CBC is a common test performed that can detect anemia, infections, Autoimmune disease, Cancer and Inflammation. TSA is a test used for cancer screening and BUN test is used to determine the condition of a patient's kidneys and liver. The Doctor asked to the Nurse to perform an EKG (Electrocardiogram) in order to check for any heart disease. After reviewing the reports and the present condition of the patient, the Doctor Dx (Diagnoses) him as having BPH (Benign Prostatic Hyperplasia) - a condition where the prostate gland enlarges in men after a certain age. The patient was Rx (Prescribed) Tab. Avodart 0.5mg PO (Per Oral - to be taken by mouth) a.c (Before food) once per day. The patient was asked to review after 3 months or prn (Pro re nata - in case of emergency).

The job of a Professional Coder is to translate the patients medical records such as diagnosis, prescription, services, laboratory and radiology results, equipments used and procedures performed into universal medical codes. Since these codes are universal, it helps medical professionals to communicate and understand effectively. A standard language can also be helpful in patient education, making it easier for the medical team to communicate and engage with the patients and improve the overall patient satisfaction.These codes are also used to claim for payments and reimbursements provided by the third-party payer companies. If the coder misinterprets the terminology, it will lead to incorrect patient care which can be a less effective treatment or dangerous in some cases. It can also lead to denial of the payment by the insurance company. Hence it is very important for the coder to understand the medical terminology to avoid blunders.