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Referring physician

A provider who sends the pt for tests or treatment.

Review of System

An inventory of the body system obtained through a series of questions that is used to identify signs or systems that the pt might be experiencing or has experienced

History of present illness


Medical Necessity

Is a criterion used by insurance companies, as well as federal programs such as medicare, when making decisions to limit or deny payment in which medical services or procedures must be justified by the pt's systems and diagnosis.

Concurrent care

Is the providing of similar services to the same pt by more than one phy on the same day. (in hospital visit)

Within normal limits


Chief complaint


Family History



If a professional claim is filed, a pt's good documentation helps establish a strong defense.

Social History

An age-appropriate review of past and current activities of pt. (smoke, alcohol consumtion)


Refers to a condistion that runs a short but relatively severe course (typical 3 to 5 days) .

Past History



A condistion persisting over a long period of time.

What is considared an established patient?

One who has recieved professional services from the physician of the same speciality who belongs to the same group practice within the past 3 years.

What is considared a new patient?

One who has not recieved any professional service the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.

What does comorbidity mean?

Underlying disease or other condition present at the time of the visit.

Define Morbidity? or (Mortality)

Is a deceased condition or state

How is documentation made when a patient fails to return for needed treatment?

Record a pt's failure to return for needed treatment by noting it in the health record, in the appointment book, and on the financial record or ledger card.
Follow-up with a telephone call or send a letter to the pt advising him/her that further treatment is indicated.

Name two reasons for documentation?

1. Defence of professional liability claim
2. Insurance carriers require accurate documentation

The SOAP method in pt medical record charting is defined as?

Subjective, Objective, Assessment, Treatment plan.

A consultation may take place in a home, office, hospital, or extended care facility?


During an external audit, points are awarded when documentation is present?


The acceptance of a subpoena by an authorized person is the equivalent of a subpoena being served personally?


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