Chapter 4 - Basic Steps of Coding Flashcards
CC
Chief Complaint
DS
Discharge summary
ER
Emergency Room
OR
Operating Room
Admitting diagnosis
the condition that requires the patient to be hospitalized
Alphabetic Index
the index found in the ICD-10-CM book for both disease conditions and procedures
Chief Complaint
the reason, in the patient’s own words, for presenting to the hospital
Differential diagnosis
when a symptom may represent a variety of diagnoses.
Discharge Summary
a review of the patient’s hospital course. This summary details the reason for admission or tests or procedures performed and how the patient responded.
Eponym
term for a disease, structure, procedure or syndrome that has been named for a person.
Main term
term that identifies disease conditions or injuries; it is identified in bold print and set flush with the left margin of each column in the Alphabetic Index.
Nonessential modifier
term that is enclosed in parentheses; its presence or absence does not affect code assignment
Principal diagnosis
condition established after study to be chiefly responsible for occasioning admission of the patient to the hospital for care.
Subterm
gives more specific information about a main term. Subterms identify site, type or etiology of a disease condition or injury. Also, modifiers that are idented to the right of the main term.
Tabular List
section of the ICD-10-CM book that contains the code listing, along with exclusion or inclusion notes.
