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HCR Final Review


4 procedures done during PE (Inspection: Observation) (Palpation: Touching) (Percussion: Striking) (Auscultation: Listening)
CC HPI ROS (Chief complaint) (History of present illness) (Review of systems)
Acute Sudden onset of infection, with a short duration.
Chronic Long duration or time frame in which a illness or injury is managed.
Sub-acute in between Acute and Chronic" A sudden onset with a long duration that is treated and managed.
Progressive Disease or injury Occurring in stages. Ex: Cancer
Intermitten A disease or injury that comes and goes without schedule. Ex: Asthma or allergies
Attending physician medical staff member who is legally responsible for the care and treatment given to a patient.
Consulting physician provider whose opinion or advice regarding evaluation or manage- ment of a specific problem is requested by another physician.
Ordering physician individual directing the selection, preparation, or administration of tests, medication, or treatment
Referring physician is a provider who sends the patient for testing or treatment. It may also be the provider who transfers the management of a patient to another physician.
Treating or performing physician provider who renders a service to a patient.
Internal Review When an audit is done by the medical office staff
External Review This system shows where documentation deficiencies occur and whether billed diagnostic and procedure codes are substantiated
SOR (Source-Oriented Record) Most common, Organized by sections
POMR (Problem-Oriented Medical Record) Tracks specific data, Cross referencing, Flow sheets
Problem focused (PF) Limited examination of the affected body area or organ
Expanded problem focused (EPF) A limited examination of the affected body area or organ system and other symptomatic or related body areas or organ systems
Detailed (D) An extended detailed examination of the affected area or organ system and other symptomatic or related body areas or organ systems
Comprehensive (C) A general multisystem examination or complete examination of a single organ system and other symptomatic or related body areas or organ systems
3 technical elements needed in a progress note Pt name, Date of service, signature and credentials
4 D's Duty, Derelict, Direct Cause, Damages
4 Natural Rights Right to Life, Right to Privacy, Right to Autonomy, Right to the means to sustain life
Created by: a.pina