a medical condition that runs a short but relatively severe course
medical staff member who is legally responsible for the care and treatment given to a patient
CC, Patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.
Medical condition persisting over a long period of time.
C, a term used to describe a level of history or physical examination.
Provision of similar services to the same patient by more than one physician the same day. (Usually seperate physical condition is present).
a provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician
continuity of care
When a physician sees a patient who has received treatment for a condition and is referred by the previous doctor for treatment of he same condition.
a discussion between the physician and a patient, family or both concerning diagnosis, recommended studies or test, prognosis, risks, and benefits of treatment, treatment options, patient and family education, and so on.
this phrase relates to intensive care provided in constant FULL bedside ATTENTION by a physician
D, a term used to describe a level of history or physical examination
a chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports: entries in the medial record such as prescription refills, telephone calls, and other pertinent data. Data in the chart must support level of service and procedures rendered.
electronic health record
EHR, a collection of medical information about a patient that resides on a computer.
Heath care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced support may be necessary. not all care provided in an emergency department of a hospital can be termed "emergency care".
the name of a disease, structure, operation, or procedure, usually derived from the name of a place or a person who discovered or described it first.
Individual who has received any professional services from the physician or another physician OF THE SAME SPECIALTY who belongs to the same group practice within the past 3 years.
expanded problem focused
EPF, A phrase used to describe a level of history or physical examination.
A retrospective review of submitted claims, medical and financial records by an insurer to investigate suspected fraud or abusive billing practices - carriers have the right to claim refunds in the event of accidental or intentional miscoding. Medicare has right to audit at any time without notice.
fax, An electronic process for transmitting graphic and written documents over telephone lines
Review of medical events in patient's family, including diseases that may be hereditary or put patient at risk.
medical record, Written or graphic information documenting facts and events during the rendering of patient care.
HC, A phrase used to describe a type of medical decision making when a patient is seen for an E/M service.
history of present illness
HPI,, Chronologic description of patient's present illness from the 1st sign symptom or from previous encounter to present.
The process of going over financial documents before and after billing to insurance carriers to determine documentation deficiencies or errors
LC, Phrase used to describe a type of medical decision making when a patient is seen for an E/M service.
medical decision making
MDM, Health care management process done after performing a history and physical examination on patient, that results in a plan of treatment.
Medical necessity of services/procedures must be justified by patient's symptoms and diagnosis - it is a criterion used by insurers in their decision to limit or deny payment.
A permanent, legal document (letter or report format) that formally states the consequences of the patient's examination or treatment
MC, A phrase used to describe a type of medical decision making when a patient is seen for an E/M service.
NP, Individual who has not received any professional services from the physician or another physician OF THE SAME SPECIALTY who belongs to the same group practice within the past 3 years.
The physician ordering nonphysician services for a patient (e.g., diagnostic laboratory tests, pharmaceutical services, or durable medical equipment) when insurance claim is submitted by a nonphysician supplier of services.
PH, Patient's past experience with illness, operations, injury and treatment.
PE or PX, Objective inspection or testing of organ systems or body areas of a patient by a physician
*primary care physician
PCP,, Physician who oversees care of patients in a managed health care plan.
Phrase used to describe a type of medical decision making when a patient is seen for an E/M service.
The process of going over financial documents before billing is submitted to the insurance company to determine documentation deficiencies and errors.
The transfer of the total or specific care of a patient from one physician to another. In managed care, a request for authorization for a specific service.
Physician who sends the patient for testing or treatment noted on insurance claim when it's submitted by the physician performing the service, (sending the patient to another physician for total or specific care).
A physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center)
The process of going over financial documents after billing is submitted to the insurance company to determine documentation deficiencies and errors.
review of systems - Inventory of body system obtained through questioning to identify signs or symptoms that the patient is experiencing or has experienced.
SH, An age-appropriate review of a patient's past and current activites (e.g., smoking, diet intake, and alcohol use).
SF, Phrase used to describe a type of medical decision making when a patient is seen for an E/M service.
A writ that commands a witness to appear at a trial or other proceedings and to give testimony.
subpoena duces tecum
a writ commanding the named person to appear at a specific time and place and to bring specific records or document with her
A physician who has responsibilities for training and supervising medial students, interns, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment
treating or performing physician
A provider who renders a service to a patient.
Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem
chief complaint - concise statement from patient describing the symptom, problem, condition, diagnosis, MD-recomended return, or other reason for the encounter
Evaluation & Management of a patient at an encounter; complexity of visit must be documented for billing.
intensive care unit
left lower quadrant of abdomen - part of sm & lrg intestine, left ureter, left ovary & fallopian tube
left upper quadrant of abdoment - left lobe of liver, stomach, spleen, part of pancreas, small & lrg intestine
right lower quadrant - parts of sm & lrg intestine, appendix, right ureter, right ovary & fallopian tube
right upper quadrant of abdomen - right lobe of liver, gallbladder, part of pancreas, small & lrg intestine
Rule Out (of a suspected diagnosis/condition) - is NOT coded for outpatient services, since they are not established. Code only the CC, signs, symptoms
within normal limits
electronic health record
history of present illness - chronological description of the development of patient's present illness, 1st sign/symptom to present
medical decision making - after obtaining history and physical exam, assessment of the data to establish a diagnosis and selecting treatment option(s).
PE or PX
physical exam -
past, family and social history
past history of illnesses, operations, injuries, treatments
a method of charting an office visit; Subjective statement of symptoms (CC), Objective findings (data from exam and tests), Assessment / diagnosis (medical decision making), Plan of treatment
chronologic detailed recording of pertinent facts and observations about a patient's health
hospital staff member legally responsible for the care and treatment given to a patient
provider whose opinion/advice regarding evaluation or management of a specific problem is requested by another physician
underlying disease or other condition present at the time of an encounter
transfer of total or specific care of a patient from one physician to another.
provision of similar services to the same patient by more than one physician on the same day; usually an underlying physical disorder accompanies an admitting diagnosis
continuity of care
patient received treatment for a condition and is thenreferred by the MD to a second MD for treatment for the same condition - both MDs are responsible for providing arrangements for continuing care.
eponyms, abbreviations, lay terms
should not be used in medical documentation