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medical documentation

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the 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  


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Created by: maxphia32