HIM FPX 4610 Assessment 1 Progress Note: The Skin
Skin Progress Note Template
Number | Medical Term | Common Term |
|---|---|---|
Example 1 | Gastritis | Inflammation or infection of the stomach |
Example 2 | Esophagogastroduodenoscopy | A procedure used to examine the throat, stomach, and small intestine through a scope |
1. | Extremities | Arms and legs (HIM FPX 4610 Assessment 1 Progress Note: The Skin) |
2. | Macules | Flat, pigmented lesion measuring less than 1 cm |
3. | Linear | A straight line or line like |
4. | Lipoma | Fatty lump usually harmless |
5. | Eczema | Inflammation of the skin accompanied by intense itching, rash & often on face, hands, or elbows |
6. | Erythematous | Flushing of the skin or redness |
7. | Oriented x3 | Oriented to person, place, and time |
8. | Superficial | On the surface of the skin |
9. | Pathology | Study of disease |
10. | Subcutaneous | Below the skin |
11. | Bilateral | Means both sides of the body |
12. | Integumentary Exam | An exam performed on the integumentary system which include examination of the skin and its accessory structures (hair, glands, and nails |
13. | Ulnar | Larger bone in the forearm |
14. | Sebaceous cyst | Small, slow growing, noncancerous bump beneath the skin |
15. | Excoriation | Means scratches, scrapes, or small skin openings |
References
“These “progress notes” serve as the repository of medical facts and clinical thinking, and are intended as a concise vehicle of communication about a patient’s condition to those who access the health record. They should be readable, easily understood, complete, accurate, and concise” (Aghili,1997).
Aghili H, Mushlin RA, Williams RM, Rose JS. Progress notes model. Proc AMIA Annu Fall
Symp. 1997: 12-6. PMID: 93575779; PMCID: PMC2233487. [In-text Citation].
Allied Health Resources: Medical Terminology Resources (2023).
Https://edcc.ibguides.com/ahe
Ehrlich A., Schroeder C., Ehrlich L., & Schroeder (2021). Medical Terminology for Health
Professions 9e ISBN: 978-0-3575-1369-9
Henderson B., & Dorsey J.L. (2019). Medical terminology for dummies.
John Wiley & Sons.
