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A chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports; entries in the medical record such as prescriptions refills, telephone calls, an other pertinent data.


The transfer of the total or specific care of a patient from one physician to another.

Emergency care

Health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced support may be necessary. Not all care provided in an emergency department of hospital can be termed "emergency care".

External audit

A review done after claims have been submitted (retrospective review) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraud or abusive billing practices.


An electronic Process for transmitting graphic and written documents over telephone lines; also referred to as fax.

Internal review

The process of going over financial documents before and after billing to insurance carriers to determine documentation deficiencies or errors.

Medical report

A permanent, legal document (letter or report format) that formally states the consequences of the patient's examination or treatment.

Referring Physician

A physician who sends the patient for testing or treatment noted on the insurance claim when it is submitted by the physician performing the services.

Retrospective review

The process of going over financial documents after billing an insurance carrier to determine documentation deficiencies and errors.


"under penalty". A writ that commands a witness to appear at a trial or other proceedings and give testimony

History of Present Illness (HPI)

A chronologic description of the development of the patient's present illness fro the first sign or symptom or from the previous encounter to the present.


Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problems.

Chief complaint (CC)

Patient' statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.

Medical Decison Marking (MDM)

Health care management process done after performing a history and physical examination on a patient that results in a plan of treatment.

Medical Necessity

The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting.

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