Across
- 2. in writing or stating a message.
- 5. health records created and stored on a computer or other electronic storage device.
- 6. what is the third step in SOAP.
- 8. a form that is used for general physical examination by health providers.
- 12. in medical terms the primary problem at the during a doctor's visit is know as?
- 13. the term used to describe a patient who does not follow medical advice he or she receives.
- 14. to examine and review a group of patient records for completeness and accuracy is called?
- 15. the type of audits that is performed by the medical staff.
- 16. the type of audits done by the government entities such as medicare or Medicaid.
- 17. allows each user's ability to work in certain areas of patient's electronic health record
- 21. the type of computerized records that is capable of reminding patients e.g. yearly checkups, follow-up care.
- 22. new patients basic information on medical visit.
- 24. medical records that is generated for individual patient created, managed and gathered in a manner that conforms to the nationally recognized interoperability standards so that it can be utilized by members of more that one healthcare.
- 25. patient medical records are also known as?
Down
- 1. theterm used to refer to the information or data that is communicated by the patient.
- 3. the process of transforming spoken notes into accurate written form
- 4. datathat comes from the physician, examinations, and test results.
- 7. source Oriented medical records can sometimes be referred.
- 9. this are subjective or internal, conditions felt by the patient.
- 10. organization that review medical records to monitor whether the care provider and fees charged meet accepted standards.
- 11. the process of recording in the medical records.
- 12. a form of medical records documentation takes the SOAP format further, breaking it down into smaller components.
- 18. process of correcting an error in an electronic charting is called.
- 19. this are objective or external factors like blood pressure, rashes or swelling.
- 20. this includes a record of the patient's past medical history; information gained at the first interview with the patient.
- 23. A set of regulations whose goals is to improve healthcare usage, combating fraud and waste.