Medical Coding & Chart Review Fundamentals

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Across
  1. 5. Healthcare professional responsible for documenting the patient encounter
  2. 6. Term used to describe a condition or event from the patient's past
  3. 8. Process of reviewing a medical record and identifying reportable information based on project guidelines
  4. 9. Healthcare setting in which the patient receives services without being admitted as an inpatient
  5. 10. Documentation section where the provider identifies or evaluates the patient's conditions or problems
  6. 11. Acronym for Hierarchical Condition Category
  7. 12. MEDICAL HISTORY Section documenting diseases, conditions, or significant health events from the patient's past
  8. 16. Information recorded in the medical record that supports the patient's care and conditions
  9. 17. Condition that typically has a sudden onset or represents a short-term illness or problem
Down
  1. 1. Interaction between a patient and healthcare provider for the purpose of receiving healthcare services
  2. 2. Abbreviation for the date on which healthcare services were provided
  3. 3. LIST Section of the medical record that lists the patient's health conditions or diagnoses
  4. 4. Health condition that is generally ongoing or long-lasting
  5. 7. TO FACE Type of encounter in which the patient and provider interact directly
  6. 10. Status indicating that a condition is currently present rather than historical
  7. 13. Documentation element used to identify and authenticate the provider responsible for the medical record
  8. 14. Provider's identification of a disease, condition, or health problem
  9. 15. Acronym associated with the classification system used to code diagnoses