The _____ is the physicians determination of what is or may be wrong with the patient based on the finding from the H&P.
The abbreviation "CC" is a statement in the patient's own words that descirbes why the person sought medical attention. The Letters "CC" stand for ___ _____.
The ____ ______ list conditions, injuries, and diseases in alphabetical order by main terms, modifying terms, and subterms.
Ancillary diagnostic services
Services that support patient diagnoses are known as ____ _____ ______.
Converting verbal or written conditions into numeric and alphanumberic designations is called _______
______ is the abbrevations, punctuation, symbols, instructional notations, and related entities that provide quidance to the medical assisstant or coder in selecting as accurate and specific code.
The _____ ______ is the information about the diagnosis or diagnoses of the patient which have been extracted from the medical documentation.
Exclusion and Excludes
______terms are always written in italics, and the word ______ is often enclosed in a box to draw particular attention to these instructions.
_______ is the current system for classifying disease to facilitate collection of uniform and comparable health information, for statistical purposes, and for indexing medical records for data storage and retrieval.
____ ______ is the initial identification of the condition or complaint the patient expresses in the outpatient medical setting.
The term ___ mustt always be followed and is found in the Alphabetic Index, volumes 2 and 3; it is a direction given to a coder to look in another place.
______ is the direction given to the coder to look elsewhere if the main term or subterm for that entry are not sufficient for coding the information.
____ is a direction given to the coder to see a specific category (3 digit code), This must always be followed
S-Subjective finding O-Obective findings A-assement P-plan for treatment
Soap notes are a system of charting that includes the following 4 things:
use additional code
The term __ _____ ___ appears only in volume 1 in those subdiviosns in which the user should add futher information by means of an additional code to give more complete picture of the diagnosis.