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Chapter 5

Assembly of the Medical Record

TermDefinition
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.
Created by: yunue03
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