E/M Flashcards
NC
newborn care
PFSH
Past, Family, Social History
Examination
The examination is the objective information the physician gathers. The examination is the findings that the physician observes during the encounter.
Coordination of Care
Coordination of care with other health care providers or agencies may be necessary for the care of a patient. In coordination of care, a physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long-term nursing facility.
BA
Body Areas
MDM
Medical Decision Making Complexity
HPI
History of Present Illness
Nature of Presenting Problem
The presenting problem is the patient’s chief complaint or the situation that leads the physician into determining the level of care necessary to diagnose and treat the patient.
Contributory Factors
The three contributory factors are counseling, coordination of care, and the nature of the presenting problem.
Observation
Observation is a status used for the classification of a patient who does not have an illness severe enough to meet acute inpatient criteria and does not require resources as intensive as an inpatient but does require hospitalization for a short period.
CC
Chief Complaint
ROS
Review of Symptoms
Medical Decision-Making Complexity (MDM)
The key component of MDM is based on the complexity of the decision the physician must make regarding the patient’s diagnosis and care.
Counseling
Counseling is a service that physicians provide to patients and their families. It involves discussion of diagnostic results, impressions, and recommended diagnostic studies; prognosis; risks and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education.
Patient Status
There are four types of patient status: New Patient, Established Patient, Outpatient, and Inpatient.
