Health record
What is the most important tool in clinical care and communication?
health records
An advantage of electronic medical records is
greater standardization in clinical medical terminology
prospective review
What is a common charting style?
SOAP
Paper documents that are no longer needed should be
shredded
The key to substantiating procedure and diagnostic code selections for proper reimbursement is
supporting documentation in the electronic health record
What does E/M stand for?
evaluation and management services
Which audit is done after billing insurance carriers?
retrospective review
If a patient fails to return for treatment, documentation should be made
in the patient's medical record, in the appointment book, and on the financial record or ledger card.
What does ROS stand for?
review of systems
What is the difference between an EHR and EMR?
An EMR is an individual physician's record for the patient. The EHR is all patient medical information.
Is a consultation the same as a referral?
NO!
Perseveration of health records is governed by
both state and federal law
What does HPI stand for?
history of present illness
Comorbidity means
underlying disease or other conditions present at the time of the visit.
What is a chief complaint?
statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter.
What is concurrent care?
When one or more service providers deliver similar services to the same patient on the same day.
Subpoena literally means
"under penalty"
The SOAP in patient medical record charting may be defined as
S-subjective, O-observations, A-auscultation, P-percussion
What does PFSH stand for?
past, family, and social histories
morbidity
Who created the list of "do not use" abbreviations?
The Joint Commission
True or False
A subpoena can be left on the physician's desk.
FALSE!
Mortality refers to
What are the four types of physical examinations?
problem focused, expanded problem focused, detailed, and comprehensive