These elements would be part of the ? history: employment, education, use…
4 elements of a history Chief Complaint (CC), History or Present Illness…
abstractionPulling out specific differences to make one solution work for multiple problems.algorithmA…
Step 1: Identify the reason for the visit( sign, symptom, diagnosis, condition…
The process of converting the medical record information into standardized codes within…
CHART NOTE CC: This established patient presents to the office today with…
Given these choices, which code has the greatest specificity? 567.23 If the…
1 A new patient presents to the physician’s office at which time…
Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles…
abdomin/o, lapar/oabdomen (two roots)acr/oextremity or topmostaden/oglandaer/oair, gasangi/o, vas/o, vascul/ovessel (three roots)arthr/ojointcarcin/ocancercardi/oheartcephal/oheadcol/o, colon/ocoloncrin/oto…
Germ TheoryMany diseases can be traced to specific causes such as bacteria,…
Assessment process of gathering information about the patient in the presenting condition…
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