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Is examination of the back an organ system or body area examination?


4 types of patient status

New, Established, Outpatient and Inpatient

1st outpatient visit is called the ______ visit, and the 2nd visit is called the _______ visit.

Initial, subsequent

First 3 factors a coder must consider when coding are patient ______, ________, and _______

Patient status, type of service, place of service

How many types of histories are there?


Which history is more complex; the problem focused history or the expanded problem focused history?

Expanded problem focused

The 4 types of examinations in order of difficulty (least to most difficult)

Problem focused, expanded problem focused, detailed, and comprehensive

The examination that is limited to the affected body area is the _____

Problem focused

What does VLBW stand for?

Very low birth weight

Term used to describe a patient who has been formally admitted to a hospital


Face to face encounter between the physician and patient

Office visit

One who has not received services from the physician or another physician in the same group (and specialty) within the last 3 years

New Patient

Advice or opinion from one physician to another physician


One who has been formally admitted to an acute health care facility


One who has received services from the physician or another physician in the same group within the last 3 years.

Established patient

Attention to an acute illness or injury that results in hospitalization


Evaluation and determination f care for a newborn infant

Newborn care

One who has not been formally admitted to a health care facility


4 types of medical decision making, in order of complexity from most to least complex

High, moderate, low, straightforward

Complexity of medical decision making is based on 3 _____


5 types of presenting problems from the most risk and least recovery to least risk and most recovery

High severity, moderate severity, low severity, self-limited/minor, minimal severity

Counseling and coordination of care are what kind of factors in most cases?


Time that is used as a guide for outpatient services is what kind of time?

Face to face or direct

Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time?


The patients ______ _______ will reflect the number of systems examined by a brief statement of the findings.

Medical record

Discussion with a patient and/or family concerning 1 or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies, prognosis, risks and benefits of treatment is ______


The history is the ______ information the patient tells the physician.


There is no distinction made between the new and established patients in this service department of a hospital


Services rendered by a physician whose opinion or advice is request by another physician or agency in the evaluation and/or treatment of a patient is a _____, whereas the physician who has primary responsibility for the patient in the hospital is called ______

Consultation, attending

When critically ill patients in medical emergencies require the constant attendance of the physician to stabilize them, what kind of care is needed?

Critical care

When care is provided for similar services to the same patient by more than one physician on the same day for different conditions, the care is ______


What is the name for the assumption of the total or specific care of a patient from one physician to another that does no constitute a consultation?

Transfer of care

An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a ____ of _____

Review of systems

If the physician who is standing by does so for 25 minutes, can he or she round the time up to 30 minutes for reporting purposes?


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