Jane Dares Health record Abbrev.

Attached is a copy of the EPIC glossary. I included the entire glossary only because the Event and Type of the 10/4/14 and 10/15/14 spreadsheet are abbreviated explanations of what actually occurred within the patient's medical record.

Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing

B. Define the abbreviations found in the surgical report. How did you find the meaning of these abbreviations?

The date the examination/assessment/evaluation was performed for the presenting diagnoses. Or, if following the applicant for an extended time, the date of onset and date of an evaluation of the condition that is recent enough to demonstrate the applicant's current level of functioning.

Under HIPAA, the DHHS established a set of codes for identifying diseases and procedures when healthcare transactions are submitted electronically (Ong, 2011). According to AMA (2015), the appropriate International Classification of Diseases (ICD) code and Current Procedural Terminology (CPT) code must be accurately documented to comply with HIPAA, which begins with scheduling the patient’s appointment. For example, to schedule an office visit for a patient diagnosed with a mental disorder referred for neuropsychological testing, the following codes must be documented when scheduled: Dx: 294 [CPT 96116 (2 hrs)] & [CPT 96119; Tech 183732 (3 hrs)].

Technology today has revolutionized the health care realm, as technology evolves so does the environment promoting quality care for that in need. This presentation will explain multiple abbreviations needed to translate and describe AMR, CMR, CMS, along with CMS – 1500, and CPT. Also, explore the meaning of DRG, EPR, HL7, ICD – 9 codes, and UB – 92.

“Patient DeAnn Kyte, forty-four years old, Caucasian, female.” That is how I imagine her doctors begin to dictate their notes from her chart. DeAnn Kyte is a patient diagnosed with Chronic Fatigue and Immune Dysfunction Syndrome. She is also my mother.

A thorough knowledge of medical terminology is extremely important in order to code. If you cannot find the term you are looking for, you will need to know where the term is located in the body in order or the exact problem you are looking for to find the term.

The debate of expanding versus focusing on home was a matter of extensive public debate in the late nineteenth century. Both sides had economic, political, and social justifications for their stance. The expansionists, explained themselves using arguments such as one of national identity and unity. Others, however, say that historically, colonialism and expansionism are contradictory to the history of America and that if the United States expands more then it will suffer the same fate as a weak power such as Spain. Despite these differences in advocacy, both sides had been driven emotionally and politically. At this point in time, the stage was set for raucous politics.

Answer the following patient information questions using the table provided. Refer to figure 4-10 on p. 83 of Health Information Technology and Management for assistance.

This policy covers common terms and abbreviations used in TB, as well as the procedure related to conducting cohort reviews.

Most of the three character codes you’ll see will be category headings. These codes would then be expanded into four, five, or six characters to add even more specificity about diagnosis.

There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The

The last two I looked at are AID (artificial insemination by donor) and AIDS (Acquired Immune deficiency syndrome) while the majority of people know what AIDS is, I had no conception that AID was even an abbreviation and just by leaving out the “S” could affect the way the patient is treated. If the patient is pregnant by AID but provider reads it is AIDS they could potentially hurt the baby and mother by giving a medication that should not be taken if pregnant or nursing. There are several abbreviations out there and just with one mistake such as incorrect capitalization, missed punctuation, or missed a symbol any of them could possibly cause grave consequences which is why it is so critical to be aware specifically to detail because you never know if it could take someone's life or cause a lifetime of health

iv  List of Abbreviations ................................................................................................................ v  Executive Summary ............................................................................................................. vi  INTRODUCTION ....................................................................................................................... 1  1.1  1.2  1.3  Background  ............................................................................................................. 1  . Statement of the Problem ....................................................................................... 2  Objective of the Study ............................................................................................. 2  General Objective ............................................................................................ 2  Specific Objective ............................................................................................ 2