Documentation Terms Flashcards
Which system is the exam component if the provider documents “range of motion”?
Musculoskeletal
The E/M section is the first divided in the CPT manual by:
Place of service
What is the “chief complaint”?
the problem, symptoms, diagnosis, or condition that brings the patient to the physician
The review of systems is:
an inventory of body systems used by the physician to identify signs and symptoms in the patients medical history
What does Medical Decision Making involve?
the complexity of establishing a diagnosis or management opinion and treatment plan
the first three components: history, examination, and medical decision making are:
the amount of resources performed by the provider to render the service
counseling, coordination of care, and the nature of the presenting problem are:
considered contributory factors in the majority of encounters
a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status is:
self-limited or minor
what is the chronological description of the development of the patient’s present illness and the reason for seeking medical care?
history or present illness (HPI)
limited to chief complaint and a brief history of the present illness:
is problem focused
disease of family members that may be hereditary or place the patient at risk is documented under which type of element?
family history
the HPI includes all but which of these: context, timing, risk, and quality
risk
the nature of presenting problems is all except which of these: symptoms, treatment, finding, illness
treatment
collection of details, related to the chief complaint, regarding possible signs, symptoms, behaviors, genetic connection, etc.
PFSH (past medical, family, social history)
recommendations for behavior modification and/or other preventive measures
anticipatory guidance
