AHIMA Professional Practice Experience Workbook

7. Folder: OP MON 08-DEC-2003 Document: OP Report 4/25/2011 In the OP report, the surgeon documented that Darlene does not have infiltration apart from that pertaining to her uterus. What is the medical term being used to describe the area of the uterus that does not have any infiltration of cancer or being of a suspicious nature?

8. Folder: OP THU 22-JAN-2004 Document: Progress Notes 4/25/2011

In the Progress Note for Darlene, a D & C procedure had been completed with the products of conception being sent over to pathology. The pathology results indicate the tissue samples from the D & C are directly pertaining to products of conception.

What is the medical term being used to describe the state/condition of the endometrial tissue?

9. Folder: OP THU 22-JAN-2004 Document: Progress Notes 4/25/2011 The physician documented that the only complaint of the patient during this encounter is painful intercourse.

What is the medical term being used to describe the patient’s complaint?

10. Folder: OP THU 22-JAN-2004 Document: Progress Notes 4/25/2011 In the Assessment portion of the Progress Note, the physician documents that the patient is experiencing a condition pertaining to the cessation of her monthly flow.

What is the medical term(s) being used to describe this condition that the patient is experiencing?

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