Question | Answer |
SX | Symptoms; subjective evidence of diease or physical disturbance. (Also symtom tab in the software.) |
HX | History (Tab) |
PX | Physical Exam (same as PE) |
DX | Diagnosis |
MEDCIN | A medical nomencalutre |
DM | Diabetes Mellitus |
RX | take thou; prescribe; treatment; therapy |
Heent | Head, eyes, ears, nose, throat |
HIT | Health Information Technology also as Healthcare Information Technology |
GI/GU | Gastrointestinal/Genitorinary body system |
ROS | Reveiw Of Systems |
Sig | instructions for labeling a prescription (Latin Signa) |
CC | Cheif Complaint |
HPI | History of Present Illness which is a chronological discription of the development of the patient present illness from the first sign or symptom or from the previous encounter to the present |
PFSH | Past History, Family History, and Social History obtained from patient or other family member |
CBC | Complete Blood Count |
EMR | Electronic Medical Record |
MDM | Medical Decision Making (a key component) |
E & M | Evaluation and Management codes which area subset of CPT-4 codes used to bill for nearly every kind of patient encounter |
NEC | Not Elsewhere Classified (diagnosis codes) |
NOS | Not Otherwise Specified (diagnosis codes) |
OIG | Office of Inspector General (Department of Health and Human Services) |
primary diagnosis | first-listed diagnosis, used in the outpatient sertting to identify the reason for the encounter |
ENT | Ears, Nose, and Throat |
Dis- | apart |
-blast | immature cell, germ cell, embryonic cell |
-dynia | pain, ache |
-ar | pertaining to |
bradykinesia | Slowness of motion or movement |
neuromyopathic | Pertaining to a disease condition involving both nerves and muscles |
myofibroma | Tumor that contains muscle and fiber |
myoplast | Surical repair of a muscle |
tenodesis | Band of fibrous connective tissue serving for the attachment of muscles to bones; a giant cell tumor of tendon sheath is a benign, small, yellow, tumorlioke nodule |
massage | Kneading that applies pressure and friction to external body tissues |
con- | with together |
quadri- | four |
syn- | together, with |
dactyl/o | finger or toe |
-oid | resemble, like, similar |
-ceps | head |
-ure | process |
combination code | A code from one section of the precedural code book combined with a code from another section that is uesed top completely describe a procedure performed |
multuiple code | dual using more than one ICD code |
morphology code | study of a form or a shape |
neoplasm | tumroms new thing form |
in situ | within a site refers to tumor cells that remain and have not invaded tissue |
benign | not progressive |
malignant | pertaining to a bad wandering |
malignant hypertension | life treating high blood presssure |
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