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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.
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Question
Answer
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: maxphia32
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