Across
- 3. The abbreviation for the date the patient received healthcare services
- 5. A status indicating that a condition is currently present
- 7. The abbreviation for the section that lists the patient's health conditions or diagnoses
- 9. The abbreviation for the section that describes the patient's past medical conditions and health history
- 10. An interaction between a patient and a healthcare provider
- 11. The abbreviation for Hierarchical Condition Category
- 12. The abbreviation for the section where the provider documents findings from examining the patient
- 13. A healthcare setting where the patient receives services without being admitted to the hospital
- 14. A health problem that has a sudden onset or is typically short-term
- 15. The abbreviation for the section that documents symptoms reported by the patient for different body systems
- 16. Letters or a title that identify the provider's professional qualification
- 17. A disease, condition, or health problem identified by the provider
- 18. A health problem that is ongoing or long-lasting
Down
- 1. The section where the provider evaluates or addresses the patient's conditions
- 2. Information recorded in the patient's medical record
- 4. Documentation that provides evidence for a reported condition or diagnosis
- 6. The abbreviation for the classification system used to code diagnoses
- 8. The documentation element that identifies and authenticates the provider
- 9. The healthcare professional who documents the patient encounter
- 11. A term used to describe a condition or event from the patient's past
- 14. The process of reviewing a medical record to identify information that can be reported
