Medical Coding

Front 1

Abstracting

Back 1

extracting data from the health record

Front 2

Admission diagnosis

Back 2

diagnosis that brings the patient to the hospital;. This will often be a symptom

Front 3

Chief complaint

Back 3

the reason, in the patient's own words, for presenting to the hospital

Front 4

Comorbidities

Back 4

preexisting diagnoses or conditions that are present on admission

Front 5

Consultant

Back 5

healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester

Front 6

Healthcare provider

Back 6

person who provides care to a patient

Front 7

Hybrid

Back 7

a combination of formats producing similar results( i.e., paper and electronic records

Front 8

Integral

Back 8

essential part of a disease process

Front 9

Physician

Back 9

licensed medical doctor

Front 10

Principal diagnosis

Back 10

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Front 11

Principal procedure

Back 11

Procedure performed for definitive treatment, rather than for diagnostic or exploratory purposes, or one that was necessary to take care of a complication.

Front 12

Progress notes

Back 12

daily recordings by healthcare providers of patient progress

Front 13

Review of systems

Back 13

question and answer period that occurs between a patient and a healthcare provider during which any healthcare issues are reviewed.