Electronic Health Records 3rd Edition by Byron Hamilton

Exercise 18

Match the terms with the definitions to be listed below.
_____ 1. SOAP format
_____ 2. BMI
_____ 3. Other Tx
_____ 4. ROS
_____ 5. PI
_____ 6. E M Coder
_____ 7. Proc
_____ 8. CC
_____ 9. History physical report
_____ 10. Template
_____ 11. Addendum
_____ 12. Office visit
_____ 13. Coordination of care
_____ 14. E M code
A. A model document predesigned with a set format and structure.
B. A structured questionnaire used by providers to gather healthcare history covering the organ systems from a patient.
C. A medical note added subsequent to the original note.
D. The documentation of the patient's medical history combined with the physical exam.
E. An encounter with a medical provider whereby the patient's chief complaints are reviewed and the patient examined.
F. A convenient way for healthcare providers to lay out the documentation of an office visit exam.
G. History of the patient's present illness.
H. The measurement of choice for studying obesity.
I. A sophisticated algorithm that determines the appropriate E M codes.
J. The presenting patient's chief healthcare complaints.
K. Section of the SOAP note that contains the performed procedure and procedure documentation.
L. An area of the SOAP note for documenting counseling and coordination of care items.
M. Resources to ensure that healthcare providers have access to all required information on a patient's conditions and treatments and to ensure the patient receives appropriate healthcare services.
N. A five-digit number used by a physician to report evaluation and management services provided to a patient.