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SBGR MedTrak
SBGR ALH 150 MEDTRAK Wk 3 (2012 EK)
| Question | Answer |
|---|---|
| treatments | treatments are actions the healthcare provider gives to the patient sometimes because a referral was done |
| scheduled testing | some referrals are for testing such as MRI and CT scan. |
| tracking a referral | the process of following-up on the progress of a referral |
| status of a referral | the step that the referral is currently in such as approved, pending or denied |
| ICD-9 | a numeric code that represents the diagnosis of the patient |
| diagnosis | what the patient's ailment is; diagnosis is coded using the CPT coding system |
| Patient history | area of the electronic chart that is completed by the physician that describes the patient's history |
| Physical exam | area of the electronic chart that is completed by the physician that describes the exam |
| multiple diagnosis | when there are multiple diagnosis MedTrak creates a blended checklist for completing the electronic chart |
| aftercare instructions | instructions for the patient to take with them when leaving the facility that outline the care they need at home |
| medications | prescriptions that may have been prescribed |
| work status | whether the patient is allowed to return to their employment |
| work restrictions | whether the patient is allowed to do reduced amounts of normal work |
| follow-up | a visit to review the outcome of previous treatment |
| assessment of care | the physician's detailed plan for treating the patient |
| summation | the physician's opinion of the patient's condition |
| case closed | the physician has closed the worker's compensation case |
| standard instructions | instructions previously loaded into the software system |
| modifiable instructions | instructions loaded into the software system that may be modified if needed |
| specific instructions | free-text field where the physician types in instructions specific to the patient |
| professional services | services performed by a physician for the benefit of the patient |
| E/M services | evaluation and management services |
| key components | factors that determine the level of E/M services; history, exam, level of medical decision making |
| levels of service | also called evaluation and management services |
| history | information regarding the patient's past illnesses, lifestyle, or family illnesses |
| exam | the review of the patient |
| decision making | level of specialized skill needed by the physician to reach a diagnosis. MDM increases when there are additional reports and information to review in order to treat the patient. |
Created by:
SBGrandRapids
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