#1
Which document contains a patient's medical history, current health conditions, and medications?
Medical record
ExplanationComprehensive repository of a patient's health information.
#2
What is the purpose of the 'CC' in a medical history?
Chief Complaint
ExplanationPrimary reason for the patient's visit or consultation.
#3
What does 'E&M' stand for in medical documentation and billing?
Evaluation and Management
ExplanationCodes for physician-patient encounter documentation.
#4
What is the purpose of the 'DNR' order in medical documentation?
Do Not Resuscitate
ExplanationPatient directive to withhold life-saving interventions.
#5
What does the acronym 'HIT' stand for in the context of healthcare documentation?
Health Information Technology
ExplanationApplies technology to manage health information.
#6
What does the term 'SOAP' stand for in medical documentation?
Subjective, Objective, Assessment, Plan
ExplanationStructured format for organizing medical notes.
#7
In medical coding, what does the acronym 'ICD' stand for?
International Classification of Diseases
ExplanationStandard system for classifying diseases and health conditions.
#8
Which document serves as a legal agreement outlining a patient's treatment choices in case they become unable to communicate their wishes?
Advance Directive
ExplanationGuidance for healthcare decisions during incapacitation.
#9
What does 'EMR' stand for in the context of medical documentation?
Electronic Medical Record
ExplanationDigital version of a patient's paper chart.
#10
Which section of a medical note typically includes the physician's findings from a physical examination?
PE - Physical Examination
ExplanationDetails the patient's physical assessment.
#11
In medical terminology, what does 'Rx' represent?
Prescription
ExplanationMedical instruction for medication.
#12
Which medical documentation format is often used for progress notes, organized under Subjective, Objective, Assessment, and Plan sections?
SOAP - Subjective, Objective, Assessment, Plan
ExplanationSystematic approach to clinical documentation.
#13
What is the purpose of the 'HPI' section in a medical note?
History of Present Illness
ExplanationDetails about the patient's current health concerns.
#14
Which standard is commonly used for electronic health records (EHR) interoperability?
HL7
ExplanationFacilitates the exchange of health information between systems.
#15
In medical billing, what is the purpose of the 'CPT' code?
Current Procedural Terminology
ExplanationNumeric code for medical procedures and services.
#16
What is the role of 'HIPAA' in healthcare documentation?
Health Insurance Portability and Accountability Act
ExplanationSafeguards patient's medical information privacy and security.
#17
What is the primary purpose of a 'MIPS' score in healthcare documentation?
Merit-based Incentive Payment System
ExplanationEncourages quality care through financial incentives.
#18
Which organization oversees the development and maintenance of the 'SNOMED CT' clinical terminology system?
IHTSDO - International Health Terminology Standards Development Organization
ExplanationManages a comprehensive clinical healthcare terminology.
#19
What does 'OCR' stand for in the context of medical documentation?
Optical Character Recognition
ExplanationConverts scanned documents into editable text.