Documentation/Records Flashcards
CC
Chief complaint and is the same as Subjective in the SOAP format.
Px
Physical examination and is the same as Objective in the SOAP format
Dx
Diagnosis and is the same as Assessment in the SOAP format.
Rx
Prescription and is the same as Plan in the SOAP format.
AHIMA
American Health Management Association- association for healthcare professionals that provides a list of documentation guidelines.-
Good Record keeping practices- 5
legible, understandable, timely, error free, reproductible
Addendum
s the addition of information that was left out of the original entry
Amendment
To add clarification or missing details from an initial documentation
Discrete Data
information that consists of separate and limited values, such as distinct points on a numeric scale, with distinct intervals between any two values
Quantifiable
which can be determined, indicated or expressed
HIE
Health Information Exchange-allows healthcare professionals and patients to appropriately access and securely share a patient’s medical information electronically
CPR
Computer based patient record-an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data
CPOE
Computerized provider order entry
a system in which provider directly enter medication orders, tests and procedures electronically,
Interoperability
the ability for different electronic record software to communicate among multiple machines
Controlled Vocabulary
means that a specific set of terms in the electronic record’s data dictionary must be used.
SNOMED CT
Systematized Nomenclature of Medicine - Clinical Terms presents data in a completely machine-readable format.
LOINC
Logical Observation Identifiers Names and Codes
RxNorm
Federal Drug Terminolgy
PHR
personal health record which is medical information that the patient maintains
EDMS
electronic data management system have implemented a hybrid medical records system Such systems use standard word-processed documents in conjunction with the electronic record
CMS-1500
is the standard claim form used to request payment for services rendered by the healthcare provider.
UB-04
The UB-04, also known as the CMS-1450, is the uniform claim form used in hospitals and other inpatient settings
CPT
Current Procedural Terminology contains codes that describe the procedures and services performed by the provider for outpatient services.
HCPCS Level II codes
5 digit alphanumeric. Not in CPT
These codes include drugs, durable medical equipment, ambulance services and prosthetic procedures.
ICD-10-CM
diagnostic codes for both inpatient and outpatient services. The ICD-10-CM is an alphanumeric classification system. A valid code may be between three and seven characters, with a decimal after the third character.
ICD-10-PCS
inpatient procedures.
7 digit. Numbers and All letters except I and O. No decimal
