Brittanys Crossword

2. stands for chief complaint, history, examination, details about the problem, drugs and dosage, assesment, and return visit
3. the process of recording information in the medical record
7. 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
10. patient information is arranged within the chart or medical record according to who supplied the data
11. 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
12. in order to trust the information in the medical record, documentation must be ______ at all times
14. customized to suit a specific specialty and style of a physician's office
15. are objective or external factors like blood pressure, rashes or swelling, that can be seen or felt or measured
16. transforming spoken notes into accurate written form
19. an electronic record of health-related information for an individual patient
22. specific information required about a population
23. one of the six c's of charting; uses precise descriptions and accepted medical terminology when describing a patient's condition
24. are subjective or internal conditions felt by the patient like pain, headache, or nausea, but may not be apparent during the examination

1. maintain a ________ tone when documenting in a medical record; never use personal comments, opinions, speculations or judgements
4. all entries in patient records must be dated to show the order in which they are made
5. allows for electronic coding of medical records, and electronic claims submission to insurance carrier
6. all forms used in the patient medical record must be completely filled out to ensure _____________.
9. contain important information about a patient's medical history and present condition
13. notice of correction in an Electronic Medical Record
14. data that comes from the patient; patient states "I am feeling dizzy"
17. the medical term used to describe a patient who does not follow the medical advice he or she receives
18. protected health information is always kept _________.
20. maintains each user's ability to work in certain areas of a patient's electronic health record
21. an electronic comprehensive medical history and record of a patient's life-long health that is collected and maintained by the individual patient