constitutional symptoms - physical makeup of the body, which include the methods the body uses
to function. for example, symptoms may consist of appearance, fever, weight loss or weight gain, hot
flashes
chief complaint (CC) - statement in patients own words describing the symptom, problem,
con...
GG MOA 110 chapter 9
constitutional symptoms - physical makeup of the body, which include the methods the body uses
to function. for example, symptoms may consist of appearance, fever, weight loss or weight gain, hot
flashes
chief complaint (CC) - statement in patients own words describing the symptom, problem,
condition or other factor that is the reason for the encounter
acronyms and abbreviations - appear in chart notes because physicians need to document quickly
and eliminate long words. the medical assistant needs to be familiar with this
acute - condition with a sudden onset that runs a short course
allergic/immunologic - system that is focused on the ability to fight disease
attending physician - medical staff member who is legally responsible for the care and treatment
given to the patient
cardiovascular (CV) - system that include the heart and blood vessels
CHEDDAR - C-chief complaint
H-history of present illness
E-examination
D-details of problems and complaints
D-drugs and dosages
A-assessment
R-return visit information or referral
chronic - condition persisting over a long period of time
, complexity of medical decision making - 1. straight forward (SF)
2. low complexity (LC)
3. moderate complexity (MC)
4. high complexity (HC)
constitutional (or general) - includes assessing the patients vital signs
consulting physician - a provider whose opinion or advice regarding evaluation or management of
a specific problem is requested by another physician
correcting a medical record - never erase or use correction fluid.
when a physician discovers an error it must be added as an addendum
diagnosis - final conclusion of the nature of disease or illness based on history, physical
examination, and sometimes diagnostic tests
digital images - some physicians(plastic surgeons, oral surgeons) may take photos of the patient
and become part of the medical record
documentation - is a clear picture of what was found, what was done, and why
documenters - are all individuals who provide health care services. this can include the
receptionist, the insurance specialist and the clinical medical assistant because we document
information as well
ears, nose, and throat (ENT) - often reviewed together because of intercommunication between
the structures of the upper respiratory tract
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