Chapter 2 - Health Record as the Foundation of Coding Flashcards
(38 cards)
1
Q
BPH
A
benign prostatic hypertrophy
2
Q
CBC
A
complete blood count
3
Q
CC
A
Chief Complaint
4
Q
CPT
A
Current Procedural Terminology
5
Q
COPD
A
chronic obstructive pulmonary disease
6
Q
DOB
A
date of birth
7
Q
ED
A
Emergency Department
8
Q
EEG
A
electroencephalogram
9
Q
EGD
A
esophagogastroduodenoscopy
10
Q
EKG
A
electrocardiogram
11
Q
ER
A
Emergency Room
12
Q
GERD
A
gastroesophageal reflux disease
13
Q
H&P
A
history and physical
14
Q
HPI
A
history of present illness
15
Q
ICU
A
Intensive care unit
16
Q
MAR
A
medication administration record
17
Q
MRA
A
magnetic resonance angiography
18
Q
MRI
A
magnetic resonance imaging
19
Q
MVP
A
mitral valve prolapse
20
Q
NPI
A
National Provider Identifier
21
Q
OP Report
A
operative report
22
Q
POA
A
present on admission
23
Q
SOAP
A
Subjective/Objective/Assessment/Plan
24
Q
TJC
A
The Joint Commission
25
TPR
temperature, pulse, and respiration
26
UHDDS
Uniform Hospital Discharge Data Set
27
UPIN
Unique Physician Identification Number
28
Abstracting
extracting data from the health record
29
Admission diagnosis
diagnosis that brings the patient to the hospital. This will often be a symptom
30
Chief Complaint
the reason, in the patient's own words, for presenting to the hospital.
31
Comorbidities
preexisting diagnoses or conditions that are present on admission.
32
Consultant
healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester.
33
Healthcare Provider
person who provides care to a patient
34
Hybrid
a combination of formats producing similar results (i.e. paper and electronic records)
35
Integral
essential part of a disease process
36
Physician
licensed medical doctor
37
Principal diagnosis
the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
38
Progress notes
daily recordings by healthcare providers of patient progress
