ADVANCED CODING CHAPTER 2
DOCUMENTATION AND CODING
REVIEW
administrative documentation - Correct Answers -Information documented in the
healthcare record regarding patient name, address, date of birth, age, next of kin,
religion, physician, and insurance coverage information. Administrative information also
describes why the patient is seeking services, consent for treatment, and use of private
healthcare information.
chief complaint (CC) - Correct Answers -Patient-provided subjective description of the
events or reason why the patient sought medical treatment.
objective documentation - Correct Answers -The physician's assessment of the patient's
current health status.
past medical history - Correct Answers -Subjective description of a patient's childhood
and adult illnesses and medical conditions.
present illness - Correct Answers -Patient-stated subjective information regarding the
current illness.
clinical documentation - Correct Answers -Information documented in the healthcare
record that records the patient's current condition, course of treatment, and relevant
current or past medical diagnoses or procedures along with anything "medical" such as
laboratory, radiology, pathology, and cytology reports.
comorbidity - Correct Answers -Condition that existed at admission and is thought to
increase the length of stay by at least 1 day for approximately 75% of patients.
complication - Correct Answers -Secondary condition that arises during hospitalization
and is thought to increase the length of stay by at least 1 day in approximately 75% of
patients.
family medical history - Correct Answers -Subjective description of immediate family
members' illnesses and/or diseases.
DOCUMENTATION AND CODING
REVIEW
administrative documentation - Correct Answers -Information documented in the
healthcare record regarding patient name, address, date of birth, age, next of kin,
religion, physician, and insurance coverage information. Administrative information also
describes why the patient is seeking services, consent for treatment, and use of private
healthcare information.
chief complaint (CC) - Correct Answers -Patient-provided subjective description of the
events or reason why the patient sought medical treatment.
objective documentation - Correct Answers -The physician's assessment of the patient's
current health status.
past medical history - Correct Answers -Subjective description of a patient's childhood
and adult illnesses and medical conditions.
present illness - Correct Answers -Patient-stated subjective information regarding the
current illness.
clinical documentation - Correct Answers -Information documented in the healthcare
record that records the patient's current condition, course of treatment, and relevant
current or past medical diagnoses or procedures along with anything "medical" such as
laboratory, radiology, pathology, and cytology reports.
comorbidity - Correct Answers -Condition that existed at admission and is thought to
increase the length of stay by at least 1 day for approximately 75% of patients.
complication - Correct Answers -Secondary condition that arises during hospitalization
and is thought to increase the length of stay by at least 1 day in approximately 75% of
patients.
family medical history - Correct Answers -Subjective description of immediate family
members' illnesses and/or diseases.
