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Med Doc Chap4

medical documentation

documentation chronological detailed recording of pertinent facts and observations about a patients health as seen in chart notes. aka: charting
constitutional component vital signs, general appearance, and nutrition
procedure to correct a medical record put line through, correct info, date and initial
subjective information symptoms
objective information seeing, feeling, smelling, or measuring data
compliance program reduce fraudulent claims and provide quality care. to have policies and procedures to accomplish uniformity and consistency in the medical record.
referral transfer of total or specific care from one doctor to another
consultation service rendered by a doctor whose opinion is requested
general principles of medical record documentation developed by CMS and physicians not required to use them
documenters all individuals providing health care
SOAP subjective objective assessment plan
medical record written or graphic document that contains facts and events during the rendering of patient care; requested by the insurance company
abstract research and finding of technical information in patient record
terminology to avoid WNL - within normal limits NEG - negative
internal review prospective review done before billing is submitted in the office
external audit retrospective review done after claims have been billed (done by insurance company)
medical necessity making sure the performance of service or procedures is consistent with diagnosis
concurrent care similar services to the patient by more than one physician on the same day
co-morbidity underlying disease or condition present at time of visit
morbidity diseased condition or state
medical record written or graphic information documenting facts and events during the rendering of patient care
external audit review of medical and financial records by insurance companies or medicare
subpoena written order signed by a judge or attorney requiring the appearance of a witness
objective information findings that can be determined by seeing, feeling, smelling or measurement
Created by: maxphia32