Brittanys Crossword

1. one of the six c's of charting; uses precise descriptions and accepted medical terminology when describing a patient's condition
2. stands for chief complaint, history, examination, details about the problem, drugs and dosage, assesment, and return visit
7. the process of recording information in the medical record
9. contain important information about a patient's medical history and present condition
12. protected health information is always kept _________.
13. an electronic comprehensive medical history and record of a patient's life-long health that is collected and maintained by the individual patient
14. data from the physician, examinations, and test results; you took the patient's temperature it was 100.5 degrees
16. the eighth leading cause of patient death in the United States
17. are objective or external factors like blood pressure, rashes or swelling, that can be seen or felt or measured
18. data that comes from the patient; patient states "I am feeling dizzy"
20. patient information is arranged within the chart or medical record according to who supplied the data
21. in order to trust the information in the medical record, documentation must be ______ at all times
22. the medical term used to describe a patient who does not follow the medical advice he or she receives
23. maintain a ________ tone when documenting in a medical record; never use personal comments, opinions, speculations or judgements

1. all entries in patient records must be dated to show the order in which they are made
3. specific information required about a population
4. 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
5. allows for electronic coding of medical records, and electronic claims submission to insurance carrier
6. an electronic record of health-related information for an individual patient
8. maintains each user's ability to work in certain areas of a patient's electronic health record
10. all forms used in the patient medical record must be completely filled out to ensure _____________.
11. customized to suit a specific specialty and style of a physician's office
15. notice of correction in an Electronic Medical Record
18. are subjective or internal conditions felt by the patient like pain, headache, or nausea, but may not be apparent during the examination
19. transforming spoken notes into accurate written form