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Med Doc Chap4
medical documentation
| Question | Answer |
|---|---|
| documentation | chronological detailed recording of pertinent facts and observations about a patients health as seen in chart notes. aka: charting |
| constitutional component | vital signs, general appearance, and nutrition |
| procedure to correct a medical record | put line through, correct info, date and initial |
| subjective information | symptoms |
| objective information | seeing, feeling, smelling, or measuring data |
| compliance program | reduce fraudulent claims and provide quality care. to have policies and procedures to accomplish uniformity and consistency in the medical record. |
| referral | transfer of total or specific care from one doctor to another |
| consultation | service rendered by a doctor whose opinion is requested |
| general principles of medical record documentation | developed by CMS and physicians not required to use them |
| documenters | all individuals providing health care |
| SOAP | subjective objective assessment plan |
| medical record | written or graphic document that contains facts and events during the rendering of patient care; requested by the insurance company |
| abstract | research and finding of technical information in patient record |
| terminology to avoid | WNL - within normal limits NEG - negative |
| internal review | prospective review done before billing is submitted in the office |
| external audit | retrospective review done after claims have been billed (done by insurance company) |
| medical necessity | making sure the performance of service or procedures is consistent with diagnosis |
| concurrent care | similar services to the patient by more than one physician on the same day |
| co-morbidity | underlying disease or condition present at time of visit |
| morbidity | diseased condition or state |
| medical record | written or graphic information documenting facts and events during the rendering of patient care |
| external audit | review of medical and financial records by insurance companies or medicare |
| subpoena | written order signed by a judge or attorney requiring the appearance of a witness |
| objective information | findings that can be determined by seeing, feeling, smelling or measurement |
Created by:
maxphia32
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