Across
- 1. use precise descriptions and accepted medical terminology when describing a patient's condition
- 2. filing system that uses the patient problem list as the source for filing within the patient medical record
- 7. an audit that is done after billing is submitted
- 8. an audit that is done before billing is submitted
- 10. What does the A stand for in the abbreviation SOAP
- 12. transforming spoken notes into accurate written form
- 14. the process of recording information in a patient's medical record
- 16. subjective or internal conditions felt by the patient
- 17. contain important information about a patient's medical history and present condition
- 18. files files that need periodic attention
Down
- 1. provide complete information that is readily understandable to others whenever you make any notation in the patient's chart
- 3. what leading cause of death in the united states is from medical errors
- 4. a record to examine and review a group of patient records for accuracy
- 5. a patient who does not follow the medical advice given
- 6. often abbreviated ROS and the results of a general physical examination
- 9. patient information is arranged within the cart or medical record according to who supplied the data
- 11. Objective or external factors
- 12. medical records should be kept up to date and be readily available when a doctor needs to see them
- 13. an electronic version of the comprehensive medical history and record of a patient's lifelong health
- 15. which of the 6 Cs means getting to the point