Chapter 2 - Health Record as the Foundation of Coding

Question 1

BPH

Answer 1

benign prostatic hypertrophy

Question 2

CBC

Answer 2

complete blood count

Question 3

CC

Answer 3

Chief Complaint

Question 4

CPT

Answer 4

Current Procedural Terminology

Question 5

COPD

Answer 5

chronic obstructive pulmonary disease

Question 6

DOB

Answer 6

date of birth

Question 7

ED

Answer 7

Emergency Department

Question 8

EEG

Answer 8

electroencephalogram

Question 9

EGD

Answer 9

esophagogastroduodenoscopy

Question 10

EKG

Answer 10

electrocardiogram

Question 11

ER

Answer 11

Emergency Room

Question 12

GERD

Answer 12

gastroesophageal reflux disease

Question 13

H&P

Answer 13

history and physical

Question 14

HPI

Answer 14

history of present illness

Question 15

ICU

Answer 15

Intensive care unit

Question 16

MAR

Answer 16

medication administration record

Question 17

MRA

Answer 17

magnetic resonance angiography

Question 18

MRI

Answer 18

magnetic resonance imaging

Question 19

MVP

Answer 19

mitral valve prolapse

Question 20

NPI

Answer 20

National Provider Identifier

Question 21

OP Report

Answer 21

operative report

Question 22

POA

Answer 22

present on admission

Question 23

SOAP

Answer 23

Subjective/Objective/Assessment/Plan

Question 24

TJC

Answer 24

The Joint Commission

Question 25

TPR

Answer 25

temperature, pulse, and respiration

Question 26

UHDDS

Answer 26

Uniform Hospital Discharge Data Set

Question 27

UPIN

Answer 27

Unique Physician Identification Number

Question 28

Abstracting

Answer 28

extracting data from the health record

Question 29

Admission diagnosis

Answer 29

diagnosis that brings the patient to the hospital. This will often be a symptom

Question 30

Chief Complaint

Answer 30

the reason, in the patient’s own words, for presenting to the hospital.

Question 31

Comorbidities

Answer 31

preexisting diagnoses or conditions that are present on admission.

Question 32

Consultant

Answer 32

healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester.

Question 33

Healthcare Provider

Answer 33

person who provides care to a patient

Question 34

Hybrid

Answer 34

a combination of formats producing similar results (i.e. paper and electronic records)

Question 35

Integral

Answer 35

essential part of a disease process

Question 36

Physician

Answer 36

licensed medical doctor

Question 37

Principal diagnosis

Answer 37

the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Question 38

Progress notes

Answer 38

daily recordings by healthcare providers of patient progress