Signatures
Chart Note Component
Abbreviations
Government and Compliance Entities
Coding
100

These are examples of provider credentials.

What is MD, PA, or NP?

100

This is the chronological description of the development of the illness.

What is the HPI (History of Present Illness)?

100

This is the abbreviation for Monitoring, Evaluating, Assessing, and Treating.

What is MEAT?

100

This Department's mission is to enhance the health and well-being of all Americans, by providing for effective health and human services.

What is the HHS (Department of Human and Health Services)?

100

This is the code to be used for Fiscal Year 2026 for Type 2 diabetes mellitus in remission.

What is E11.A?

200

The PCO Coding Operations acceptable length of time to sign and close a note. 

What is 3 business days?

200

The area of a note that contains the treatment of medical conditions.

What is the Plan?

200

This is the abbreviation for Rule Out.

What is R/O?

200

This Rule protects personal health information and gives patients a variety of rights. 

What is HIPAA?

200

This is the code you report for asthma in a patient with COPD.

What is J44.89? Coding Clinic, 2nd quarter 2024

300

This is where an electronic signature must be located. 

What is the end of the note/document?

300

This is the main reason the patient was seen.

What is the Chief Complaint (CC)?

300

This is the abbreviation of Diagnosis, Status, and Plan?

What is DSP?

300

This is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program.

What is CMS (Centers for Medicare and Medicaid)?

300

This is the code category that reports obesity designated by class.

What is E66.8, E66.81, E66.811, E66.812, E66.813, E66.89?

400

This type of signature does not require a signature date.

What is a handwritten signature?

400

This is the series of questions asked by the healthcare provider to identify signs and symptoms.

What is the ROS (Review of Systems)?

400

This is the abbreviation for a chest x-ray.

What is CXR?

400

This is the entity that provides health care to individuals of age 65 or older, disabled and End-Stage Renal Disease (ESRD).

What is Medicare?

400

This is the code you report when clinician documents in the assessment "calcified granuloma of the lung".

What is J98.4? Coding Clinic, 2nd quarter 2024

500

The point of signature on a medical document is to...

What is acceptance, approval or obligation?

500

This is the list of current and active diagnosis as well as past diagnosis relevant to the current care of the patient.

What is the Problem List?

500

This is the abbreviation for Dyspnea on Exertion.

What is DOE?

500

This Act supports the development of a nationwide health IT infrastructure. 

What is the Health Information Technology for Economic and Clinical Health (HITECH)?

500

This is the code you report when clinician documents: "Polyneuropathy due to pre-diabetes evidenced by abnormal gait, increased sensitivity to pain in left upper extremity and left lower extremity".

What is G62.89? Coding Clinic, 3rd quarter 2024