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Brittanys Crossword

  1. 3. an electronic comprehensive medical history and record of a patient's life-long health that is collected and maintained by the individual patient
  2. 5. stands for chief complaint, history, examination, details about the problem, drugs and dosage, assesment, and return visit
  3. 8. specific information required about a population
  4. 12. an electronic record of health-related information for an individual patient
  5. 13. all entries in patient records must be dated to show the order in which they are made
  6. 15. 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
  7. 16. protected health information is always kept _________.
  8. 18. maintains each user's ability to work in certain areas of a patient's electronic health record
  9. 19. patient information is arranged within the chart or medical record according to who supplied the data
  10. 20. transforming spoken notes into accurate written form
  11. 22. are objective or external factors like blood pressure, rashes or swelling, that can be seen or felt or measured
  1. 1. allows for electronic coding of medical records, and electronic claims submission to insurance carrier
  2. 2. data that comes from the patient; patient states "I am feeling dizzy"
  3. 3. maintain a ________ tone when documenting in a medical record; never use personal comments, opinions, speculations or judgements
  4. 4. the medical term used to describe a patient who does not follow the medical advice he or she receives
  5. 6. the eighth leading cause of patient death in the United States
  6. 7. customized to suit a specific specialty and style of a physician's office
  7. 9. data from the physician, examinations, and test results; you took the patient's temperature it was 100.5 degrees
  8. 10. contain important information about a patient's medical history and present condition
  9. 11. all forms used in the patient medical record must be completely filled out to ensure _____________.
  10. 14. the process of recording information in the medical record
  11. 17. notice of correction in an Electronic Medical Record
  12. 18. in order to trust the information in the medical record, documentation must be ______ at all times
  13. 19. are subjective or internal conditions felt by the patient like pain, headache, or nausea, but may not be apparent during the examination
  14. 21. one of the six c's of charting; uses precise descriptions and accepted medical terminology when describing a patient's condition