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SBGR MedTrak

SBGR ALH 150 MEDTRAK Wk 3 (2012 EK)

treatments treatments are actions the healthcare provider gives to the patient sometimes because a referral was done
scheduled testing some referrals are for testing such as MRI and CT scan.
tracking a referral the process of following-up on the progress of a referral
status of a referral the step that the referral is currently in such as approved, pending or denied
ICD-9 a numeric code that represents the diagnosis of the patient
diagnosis what the patient's ailment is; diagnosis is coded using the CPT coding system
Patient history area of the electronic chart that is completed by the physician that describes the patient's history
Physical exam area of the electronic chart that is completed by the physician that describes the exam
multiple diagnosis when there are multiple diagnosis MedTrak creates a blended checklist for completing the electronic chart
aftercare instructions instructions for the patient to take with them when leaving the facility that outline the care they need at home
medications prescriptions that may have been prescribed
work status whether the patient is allowed to return to their employment
work restrictions whether the patient is allowed to do reduced amounts of normal work
follow-up a visit to review the outcome of previous treatment
assessment of care the physician's detailed plan for treating the patient
summation the physician's opinion of the patient's condition
case closed the physician has closed the worker's compensation case
standard instructions instructions previously loaded into the software system
modifiable instructions instructions loaded into the software system that may be modified if needed
specific instructions free-text field where the physician types in instructions specific to the patient
professional services services performed by a physician for the benefit of the patient
E/M services evaluation and management services
key components factors that determine the level of E/M services; history, exam, level of medical decision making
levels of service also called evaluation and management services
history information regarding the patient's past illnesses, lifestyle, or family illnesses
exam the review of the patient
decision making level of specialized skill needed by the physician to reach a diagnosis. MDM increases when there are additional reports and information to review in order to treat the patient.
Created by: SBGrandRapids