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12 Cards in this Set
- Front
- Back
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Medcin |
A medical nomenclature and knowledge base developed by Medicomp Systems, Inc. Recognized as a national standard, it is incorporated in many commercial EHR systems as well as the U.S. Department of Defense CHCS II System. |
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ICD-9-CM |
International Classification of Diseases. 9th revision. Clinical Modifications. system of standardized codes to classify diseased previously reason of death. |
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Explain the difference between an EHR nomenclature and a billing code set. |
A nomenclature is a code set designed specifically to record medical observations. EHR nomenclatures have many more codes used to describe the details exam. Billing codes represent simply that the service was rendered. |
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Which screen do you use to set the reason for the visit? |
By clicking on "select", then selecting patient and clicking on "new encounter". Once there, from the menu option select the reason such as 10 minute visit, 30 minute visit, echo lab, etc. |
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How do you enter vital signs? |
By going to "forms" and then selecting the "vitals" form and entering he vitals. |
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How do you load a list? |
By selecting "lists" on the tools options and selecting from the list of lists. |
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Definition of ROS |
Review of systems. An inventory of body systems starting from the head down, often referred to as ROS. HEENT, Cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematologic, and allergic |
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Definition of HX |
History- |
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HPI |
History of present illness |
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DX |
Diagnosis |
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HEENT |
Head, ear, eyes, nose and throat |
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URI |
Upper respiratory infection. |
