15 terms

Mod E week 2 Theory

An expanded problem-focused examination is a/an
limited examination of the affected body area.
Repair or lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as
who may accept a subpoena?
Both A and b
Waht does comobidity mean?
Underlying diseases or other conditions present at the time of the visit
A diseased condition or state is known as
The official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the"
All of the above
Reasons for documentation are
Both a and b
The SOAP in patient medical record charting may be defined as
S-subjective, O-ovjective, A-assessment, P-plan
In dealing with managed care plans, a referral is
Both b and c
The key to substantiating procedure and diagnostic code selections for proper reimbursement is
supporting documentation in the health record.
the abbreviation HPI stands for ___ __ ___ ____
history of present illness
An internal review known as ____ ____ is done after billing insurance carriers.
retrospective review
The abbreviation PH stands for ____ ____.
past history
An inventory of body systems obtained through a series of questions that are used to indentify signs and/or symptoms of the patient is known as a/an ____ ____ ____
review of system
The abbreviation SH stands for ____ ____.
social history.