Brittanys Crossword

2. notice of correction in an Electronic Medical Record
3. patient information is arranged within the chart or medical record according to who supplied the data
5. allows for electronic coding of medical records, and electronic claims submission to insurance carrier
6. the medical term used to describe a patient who does not follow the medical advice he or she receives
7. specific information required about a population
10. the process of recording information in the medical record
11. an electronic record of health-related information for an individual patient
12. customized to suit a specific specialty and style of a physician's office
14. one of the six c's of charting; uses precise descriptions and accepted medical terminology when describing a patient's condition
16. transforming spoken notes into accurate written form
18. all entries in patient records must be dated to show the order in which they are made
19. are objective or external factors like blood pressure, rashes or swelling, that can be seen or felt or measured
20. to examine or review a group of patient records for completeness and accuracy; as related to their ability to back up the charges sent to health insurance carriers
21. all forms used in the patient medical record must be completely filled out to ensure _____________.
23. in order to trust the information in the medical record, documentation must be ______ at all times

1. contain important information about a patient's medical history and present condition
3. data that comes from the patient; patient states "I am feeling dizzy"
4. the eighth leading cause of patient death in the United States
8. data from the physician, examinations, and test results; you took the patient's temperature it was 100.5 degrees
9. maintain a ________ tone when documenting in a medical record; never use personal comments, opinions, speculations or judgements
13. stands for chief complaint, history, examination, details about the problem, drugs and dosage, assesment, and return visit
15. an electronic comprehensive medical history and record of a patient's life-long health that is collected and maintained by the individual patient
17. maintains each user's ability to work in certain areas of a patient's electronic health record
18. protected health information is always kept _________.
22. are subjective or internal conditions felt by the patient like pain, headache, or nausea, but may not be apparent during the examination