billing and coding Flashcards
billing
cc
chief complaint
EHR
Electronic Health Record
Demographics
Patients name, date of birth, contact ,info ,ssn ,employer ,number, insurance information.
PMH
past medical history
Reasons to have accurate records
*proof needed for a legal defense
*money
*higher quality of care
track vital statics
continuity of care ( allowing the pt to receive the most benefit..)
the smooth continuation of care from one provider to another allowing the pt to receive the most benefit with no intimation or duplication of care.
who owns the medical record
the place where the chart was created
anaphylaxis
a rapidly progressing, life threating allergic reaction.
what is SOAP
subjective data
objective data
assement
plan ( includes provides suggested treatments)
what is HITECH
hipaa on steroids
HPI
history of present illness
HITECH
Health information technology for economic and clinical health
what is HPI
concise account of problem more detail than cc
FH
family history
ROS
range of system
what is the advantage of EHR
Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
what is jargon?
the vocabulary of particular profession as opposed to common everyday form.
pitch ( depth of a tone..)
the depth of a tone or sound a distinctive quality of sound.
triage
classify the injury
how do you create a positive impression over the phone
you smile:)