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MED254 MED OFF PRO 2
MED254 CH 11 KEY TERMS
| DEFINITION | TERM |
|---|---|
| MED254 CH 11 KEY TERMS | |
| To examine and review a group of patient records for completeness and accuracy— particularly as related to their ability to back up the charges sent to health insurance carriers for reimbursement. | audit (aw’dit) |
| C: Chief complaint. H: History. E: Examination. D: Details of problem and complaints. D: Drugs and dosage. A: Assessment. R: Return visit information or referral, if applicable. | CHEDDAR (ched’er) |
| Statistical data relating to the population and particular groups within it. | demographic (dĕ-mŏ-gră’fik) |
| The recording of information in a patient’s medical record; includes detailed notes about each contact with the patient and about the treatment plan, patient progress, and treatment outcomes. | documentation (dok’yū-mĕn-tā’shŭn) |
| The term used to describe a patient who does not follow the medical advice given. | noncompliant (nŏn-kŏm-plī’ănt) |
| Pertaining to data that are readily apparent and measurable, such as vital signs, test results, or physical examination findings. | objective (ŏb-jek’tĭv) |
| A compilation of important information about a patient’s medical history and present condition. | patient record/chart (pā’shĕnt rĕk’ŏrd/chärt) |
| The problem-oriented medical record system for keeping patients’ charts. Information in a POMR includes the database of information about the patient and the patient’s condition, the problem list, the diagnostic and treatment plan, and progress notes. | problem-oriented medical record POMR |
| A process of gathering information about a patient’s health history regardless of apparent relevance to the chief complaint. | review of systems (rē-vū’ sis’tĕm) ROS |
| An objective, or external, factor, such as blood pressure, rash, or swelling, that can be seen or felt by the physician or measured by an instrument. | sign (sīn) |
| Source-oriented medical record. The information in this type of medical record is arranged according to the provider type supplying the data. | source-oriented medical record SOMR |
| Pertaining to information that is obtained from conversation with a person or patient. | subjective (sŭb-jĕk’tĭv) |
| An approach to medical records documentation that documents information in the following order: S (subjective data), O (objective data), A (assessment), P (plan of action). | Subjective, Objective, Assessment, Plan SOAP (sōp) |
| A subjective, or internal, condition felt by a patient, such as pain, headache, or nausea, or another indication that generally cannot be seen or felt by the doctor or measured by instruments. | symptom (simp’tŏm) |
| The transforming of spoken notes into accurate written form. | transcription (trăn-skrĭp’shŭn) |
Created by:
C to the C
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