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Key Terms chapter 4 (15)
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Documentation
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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.
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Terms in this set (15)
Documentation
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.
Referral
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.
Facsimile
An electronic Process for transmitting graphic and written documents over telephone lines; also referred to as fax.
