Documentation

Question 1

When a healthcare provider is placed on a prepayment audit, and reviewed by ins. company

Accepted Answer

Prepayment Audit

Question 2

Documentation of the patient’s previous experiences with illnesses, operations, injuries, and treatments is known as the

Accepted Answer

Past history

Question 3

When the pain/symptom occurs.

Accepted Answer

Timing

Question 4

Preservation of health records is governed by

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both state law and local law

Question 5

Provider who is the medical staff member legally responsible for the care and treatment given to a patient.

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Attending physician

Question 6

Transfer of the total care of a patient from one physician to another.

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Referral

Question 7

Process of chronologically recording pertinent facts and observation about a patients health

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Documentation

Question 8

Discussion with a patient, family, or both about diagnostic results and instructions for treatment.

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Counseling

Question 9

A diseased condition or state is known as

Accepted Answer

Morbidity.

Question 10

Written or graphic documentation of facts and events during the patient care visit

Accepted Answer

Health record

Question 11

Character of the symptom/pain (burning, gnawing).

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Quality

Question 12

Cut in a horizontal fashion

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Undermining

Question 13

Providing similar services to the same patient by more than one physician on the same day

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Concurrent care

Question 14

This has a record of All the patients Medical information

Accepted Answer

Health record

Question 15

Inventory of body systems obtained through a series of questions that used to identify signs and symptoms of the patient

Accepted Answer

Review of systems

Question 16

A disease that runs a short but relatively severe course is referred to as

Accepted Answer

Acute

Question 17

Intensive care provided during an acute life-threatening condition requires constant bedside attention by the physician.

Accepted Answer

Critical care

Question 18

An age-appropriate review of past and current activities of the patient (smoking or use of alcohol) is known as a/an

Accepted Answer

Social history

Question 19

Area of the body in which the symptom is occurring.

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Location

Question 20

Things done to make the symptom/pain worse or better.

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Modifying factors

Question 21

lysis of adhesions

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Destruction of scar tissue

Question 22

Services rendered by a physician whose opinion is requested by another physician for evaluating a patient’s illness.

Accepted Answer

Consultation

Question 23

Situation associated with the pain/symptom

Accepted Answer

Context

Question 24

Review of medical events in the patient’s family, including diseases that may be hereditary, is known as a/an

Accepted Answer

Family history

Question 25

If you are in doubt about the documentation in any health record, to obtain the most specific and accurate terminology

Accepted Answer

Query

Question 26

Provider who sends the patient for tests or treatment.

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Referring physician

Question 27

A Disease, syndrome, procedure name after a person

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Eponym

Question 28

The term refers to a disease that persists over a long time.

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Chronic

Question 29

Degree of symptom and/or pain on a scale from 1 to 10.

Accepted Answer

Serverity

Question 30

Chronologically recording pertinent facts and observations about the patient&#x27;s health

Accepted Answer

Documentation

Question 31

Symptom/pain and other changes that are noted when the symptom/pain occurs.

Accepted Answer

Associated signs and symptoms

Question 32

How long the symptom/pain has been present and how long it lasts when the patient has it.

Accepted Answer

Duration

Question 33

Provider whose opinion is requested by another physician about evaluation and management of a specific problem.

Accepted Answer

Consulting physician

Question 34

To take apart

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Take down

Question 35

Care provided during a life-threatening condition in the hospital emergency department.

Accepted Answer

Emergency

Question 36

Individual who directs the selection, preparation, or administration of tests, medications, or treatment.

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Ordering physician

Question 37

List of all staff, names, job title, signature & initials

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Signature log

Question 38

Provider who renders a service to a patient

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Treating or performing physician

Question 39

A legal document signed by a judge or an attorney in the name of a judge

Accepted Answer

Subpoena

Question 40

Individual physician's record for the patient

Accepted Answer

Medical record

Documentation

Questions 40

Documentation

Questions 40