patient’s health record

where important information about a patient's medical history and present condition is found

organization that reviews patient health records to monitor whether the care provided and the fee charged met accepted standards

hospital discharge summary

a summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization

patient registration form

first document found in a patient's financial record

use of precise descriptions and accepted medical terminology when describing a patient's condition

objective, or external, factor that can be seen or felt by the physician or measured by an instrument

subjective, or internal, condition that is felt by the patient but are not necessarily apparent in a physical examination

type of documentation that provides an orderly series of steps for dealing with any medical case

S section of SOAP documentation

data that comes directly from the patient

O section of SOAP documentation

data that comes from examination results and from the physician

A section of SOAP documentation

diagnosis or impression of a patient's problem; assessment

at the time of a patients visit

patient's written consent

necessary to release a patient's record to the patient's insurance company

process of recording information in the medical record

section of the CHEDDAR format of documentation where the diagnosis can be found

section of the CHEDDAR format of documentation where the presenting problem can be found

prospective internal audit

audits performed before billing is submitted

retrospective internal audit

audit performed after billing is submitted

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MOA Chapter 11

Term	Definition
patient’s health record	where important information about a patient's medical history and present condition is found
The Joint Commission	organization that reviews patient health records to monitor whether the care provided and the fee charged met accepted standards
hospital discharge summary	a summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization
patient registration form	first document found in a patient's financial record
clarity	use of precise descriptions and accepted medical terminology when describing a patient's condition
sign	objective, or external, factor that can be seen or felt by the physician or measured by an instrument
symptom	subjective, or internal, condition that is felt by the patient but are not necessarily apparent in a physical examination
SOAP	type of documentation that provides an orderly series of steps for dealing with any medical case
S section of SOAP documentation	data that comes directly from the patient
O section of SOAP documentation	data that comes from examination results and from the physician
A section of SOAP documentation	diagnosis or impression of a patient's problem; assessment
P section of SOAP documentation	plan of action
due course	at the time of a patients visit
patient's written consent	necessary to release a patient's record to the patient's insurance company
documentation	process of recording information in the medical record
assessment	section of the CHEDDAR format of documentation where the diagnosis can be found
the C section	section of the CHEDDAR format of documentation where the presenting problem can be found
prospective internal audit	audits performed before billing is submitted
retrospective internal audit	audit performed after billing is submitted

Created by: Kilby-YTI

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