TY - CHAP M1 - Book, Section TI - Medical Records, Test Results, and Referrals A1 - Hull, Melodie PY - 2013 T2 - Medical Language: Terminology in Context AB - Patient UpdateIn Chapter 5, our patient, 74-year-old Zane Davis, presented as confused in the ER at Okla Trauma Center. He was rushed there by Rescue Unit 155 from the scene of a motor vehicle accident; it remains unclear if he was the driver of one of the vehicles. Mr. Davis did not appear to sustain any overt traumatic injury; however, he was transported to Okla Trauma on suspicion that he may have been having a cerebrovascular accident (CVA). In the ER, he was triaged, and the physician explored the possibility that the patient had just had one or more transient ischemic attacks (TIAs). The treatment team members were concerned that Mr. Davis's suspected TIA could be the precursor to a CVA, and there was even some speculation that he may have had a CVA en route to the hospital. Mr. Davis was given a computed tomography (CT) scan to determine this. The results confirmed that the patient had coronary artery disease (CAD), but they did not reveal any blockages or ruptures of blood vessels. Mr. Davis was also referred to a cardiologist and given further testing to completely rule out the possibility that he had experienced a stroke. At the time of his arrival at Okla Trauma, Mr. Davis had also been incontinent of urine, and the cause of his incontinence is also a concern to the team. A urinary catheter was inserted as an intermediary precaution related to the incontinence but also because of the patient's level of confusion (see Chapter 5).As the treatment team awaits the results of the patient's diagnostic reports and continues to monitor his condition, Mr. Davis has been admitted to the intensive care unit (ICU) as a standard protocol for cardiovascular emergencies (see Chapter 5). His confusion has lifted, and he is now oriented × 3. He remains in bed. His heart, pulse, and respirations are being monitored frequently, as are his O2SATs (see Chapter 5). To complete the intake data for Mr. Davis, Victor, the medical unit clerk in the ICU, is now speaking with Larry from the Admissions Division of Medical Records at Okla Trauma Center. Victor will review some of the patient's basic biographical data, confirm a variety of orders that have been given for the patient's diagnosis and treatment, and determine if lab work has been completed for the patient."Hi, this is Victor in the ICU. We've just admitted a Zane Davis, 74 years old. Is there someone there I can speak to about this patient?" The voice on the other end of the phone identified himself as "Larry in Admissions" and confirmed that he would be able to assist. Victor thanked him and began the process of reviewing, confirming, and adding to the admission record for Mr. Davis. First, he confirmed the spelling of Mr. Davis's name, his date of birth, and his address, and he then confirmed Mr. Davis's insurance information. He also asked about the patient's next of kin."We have here that Mrs. Stevie-Rose Davis is his wife, and ... SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/04/20 UR - fadavispt.mhmedical.com/content.aspx?aid=1154814983 ER -