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Chapter 5
Assembly of the Medical Record
Term | Definition |
---|---|
Autopsy | A postdeath examination of the body, including dissection of the internal organs, to determine the cause of death. |
CBC | Complete blood count. |
CPT | Current Procedural Terminology. Used to code procedures. |
DRG | Diagnoses Related Group. A group of diagnoses with similarities in treatment and resource consumption. |
Differential diagnosis | A tentative diagnosis, based on symptoms, made before and diagnostic tests are performed. |
EKG | Electrocardiogram. |
ICD | International Classification of Diseases. Used to code diagnoses and procedures. |
Principal diagnosis | The diagnosis that, after study, proves to be the reason for a patient's admission. |
Respiratory and physical therapy | Therapy to assist a patient with breathing and physical movement, respectively. |
Secondary diagnosis | An additional diagnosis which was treated or was present during the patient's hospitalization. |