chptr 23 Flashcards
anticipatory guidance
recommendations for behavior modification and/or other preventive measures
basic personal services
services that include washing/bathing, dressing, and undressing, assistance in taking medications, and assistance getting in and out of bed
care plan oversight services
e/m of a patient, reported in 30- day periods, including infrequent supervision along with preencounter and post encounter work, such as reading test results and assessment of notes
chief complaint (cc)
the primary reasons why the patient has come for this encounter, in the patients own words
consultation
an encounter for purposes of a second physicians opinion or advise, requested by another physician, regarding the management of a patients specific health concern. A consultation is planned to be a short-term relationship between a health care professionals and a patient
critical care services
care services for an acutely i’ll or injured patient with a high risk for life threatening development
end stage renal disease
chronic, irreversible kidney disease requiring regular treatments
global surgical package
a group of services already included in the code for the operation and not reported separately
history of present illness
the collection of details about the patient take chief complaint , the current issue that prompted this encounter: duration, specific signs and symptoms etc
hospice
an organization that provides services to terminally ill patients and their families
interval
the time measured between one point and another, such as between physician visits
level of patient history
the amount of detail involved in the documentation of patient history
new patient
a person who has not received any professional services within the past 3 years from either provider or another provider of the same specialty who belongs to the same group practice
nursing facility
a facility that provides skilled nursing treatment and attention along with limited medical care for its (usually long term) residents, who do not require acute care services (hospitalization)
past family social history (pfsh)
collection of details, related to the chief complaint, regarding possible signs, symptoms, behaviors, genetic connection ect
