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Assembly of the Medical Record

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Term
Definition
Autopsy   A postdeath examination of the body, including dissection of the internal organs, to determine the cause of death.  
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CBC   Complete blood count.  
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CPT   Current Procedural Terminology. Used to code procedures.  
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DRG   Diagnoses Related Group. A group of diagnoses with similarities in treatment and resource consumption.  
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Differential diagnosis   A tentative diagnosis, based on symptoms, made before and diagnostic tests are performed.  
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EKG   Electrocardiogram.  
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ICD   International Classification of Diseases. Used to code diagnoses and procedures.  
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Principal diagnosis   The diagnosis that, after study, proves to be the reason for a patient's admission.  
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Respiratory and physical therapy   Therapy to assist a patient with breathing and physical movement, respectively.  
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Secondary diagnosis   An additional diagnosis which was treated or was present during the patient's hospitalization.  
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Created by: yunue03
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