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Current Procedural Terminology - a systematic listing and coding of procedures and services.


Clinical Modifications - morbitidy coding; indexing of hospital records by disease and operations and diagnosis.

Informed Consent

Doctors are ethically bound to encourage acceptance of the therapeutic recommendation judged to be in the person's best interest. But refusal of the patient to do so is not to be considered attempted suicide.


The right of individuals over the age of 18 to manage their own affairs, conducet business, and make health care decisions. A person can be declared incometent by a court or willingly transfer the right to someone else.

Power of attorney for health

A document that allows someone else to make medical treatment decisions on his/her behalf.

Living Will

A document, sometimes called a directive to doctors, that expresses a person's wishes regarding medical intervention when very ill or near death.

Parts of Medicare

Part A - hospital insurance
Part B - provides general medical insurance

Diseases which must immediately be reported to the government by telephone

cholera, haemophilus influenzae, plague, rubella, animal bites, diphtheria, poliomyelitis, anthrax, botulism, measles, pertussis, rabies, tularemia

SOAP notes

S - subjective
O - objective
A - assessment
P - plan

A complete medical record provides:

ID, prior med history, dated consent forms, assessment, plan of care, date/time/description of each treatment, progress notes/observations/clinical findings, discharge summary with final diagnosis/prognosis, and clear authorship of all records

If an error is made on a record

circle the error or draw a single line through it. Write "error" on the side of it along with date, time, and your initials.

Who may have rights to the med files

Both licensing, accrediting bodies and patients' employers may have access in some states to determine charting and care or worker's comp.

Time limit authorized for file access once waivered

90 days max

Time employee medical records must be kept

30 years past employment

Time employee training records must be kept

3 years

Time copies of med files must be sent to requesting patients

30 days

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