chptr 2 abstracting clinical documentation

Question 1

abstracting

Answer 1

the process of identifying the relevant words or phrases in healthcare documentation in order to determine the best , most appropriate code(s)

Question 2

assume

Answer 2

suppose to be the case, without proof; guess the intended details

Question 3

co morbidity

Answer 3

a separate diagnosis existing in the same patient at the same time as an unrelated diagnosis

Question 4

demographic

Answer 4

demographic details include the patients name, address, date of birth, and other personal details, not specifically related to health

Question 5

interpret

Answer 5

explain the meaning of; convert a meaning from one language to another

Question 6

manifestation

Answer 6

a condition that develops as the result of another, underlying condition

Question 7

query

Answer 7

to ask

Question 8

sequela

Answer 8

a cause and effect relationship between an original condition that has been resolved with a current condition; also known as late effect

Question 9

signs

Answer 9

measurable indicators of a patient’s health status

Question 10

symptom

Answer 10

a subjective sensation or departure from the norm as related by the patient