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