statement in the patient's own words that describes the reason for the visit; should be documented in the patient's own words.
condition that occurs at the same time as the primary diagnosis and affects the patient's treatment or recovery from the primary condition.
ways of identifying special instructions through the use of abbreviations, symbols, and other short descriptions.
coordination of care
approach to managing a patient's care when a provider asks other health care providers to assist.
discussion with the patient or family conducted by a health care provider concerning the patient's diagnosis, test results, and other approaches to medical care.
determination of the nature of a disease based on signs, symptoms, and laboratory findings.
person or persons for whom something (e.g., disease, procedure) has been named, or the name so derived (e.g., a simple urethropexy is known as the Marshall-Marchetti-Kravitz procedure).
person who has been treated by a member of the health care team in the past 3 years.
coding to the highest level of documentation available; not using only a three-digit when a four-or five-digit code exits to better describe the disease or procedure.
rules that define items necessary to interpret and report procedures and services appropriately (e.g., for CPT codes).
history of present illness (HPI)
chronological description of the patient's present illness from the first sign or symptom to the present.