Medical Documentation Proofreading Example 7

Proofreading

She is an 79-year-old white female who present in with acute chole cystitis and underwent  attempted laparoscopic Cholecystectomy 8 day ago. The patient has required conversion for an  open procedure due to difficult anatomy. Her post operative course has been lengthened due to  a prolonged ileus, which resolved by tetracycline and Reglan. The patient is starting to improve  or gain more strength. She is tolerating his regular deit. She had an bowel movement today and  are continuing to improve. I anticipated another 3 days in the hospital for strengthening, or  continued TPN and resolution of eleveted White count.

 

cholecystectomy

Answer

She is a 79-year-old white female who presented in with acute cholecystitis and underwent  attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an  open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve and gain more strength. She is tolerating her regular diet. She had a bowel movement today and is continuing to improve. I anticipate another 3 days in the hospital for strengthening and  continued TPN and resolution of elevated white count.

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