medical documentation

medical documentation

A term relating to a patient care or medical record. Typically, medical documentation consists of operative notes, progress notes, physician orders, physician certification, physical therapy notes, ER records, or other notes and/or written documents; it may include ECG/EKG, tracings, images, X-rays, videotapes and other media.

medical documentation

Managed care A term relating to a Pt care record or medical record, which may be written and include EKG, tracings, X-rays, videotapes and other media; typically, operative notes, progress notes, physician orders, physician certification, physical therapy notes, ER records, other notes and/or written documents are included
References in periodicals archive ?
9, 2015 /PRNewswire/ --Attention physician educators: use this training method employed in medical schools when teaching your physicians and clinical staff about medical documentation and coding and compliance.
He states in the complaint: "I have since received from the Crown Prosecution Service a copy of all the medical documentation that South Wales Police secured from ABMU and was absolutely astonished to learn that the secured documentation did not include any of my family's computer records, which was the main purpose of the request.
A South Carolina nurse, Shannon Pierce, developed CareCam's technology as a way to improve medical documentation by incorporating videos.
The London Times quoted Proton Therapy Centre Czech saying that they are ready to begin treatment on Ashya King as soon as they receive proper medical documentation from doctors in U.
One important change for vegans and others avoiding dairy products is that medical documentation is no longer needed for program participants to get vouchers for soy beverages and calcium-set tofu in place of cow's milk.
In the past, medical documentation involved lots of paper work and was time consuming.
8220;With many providers across the nation continuing to struggle with medical documentation responsibilities, Elite is looking forward to showcasing its proven solutions that allow providers to deliver only highest quality patient care without being slowed down and distracted by burdensome administrative duties.
Van de Vliet added: "Decisions on her classification were made on the basis of the available medical documentation at the time, although post-career a more conclusive diagnosis was made on the athlete.
Medical Electronic Attachment (MEA) along with its sister company National Electronic Attachment (NEA), is the recognized leader in secure health information exchange, offers solutions that enable the capture, transmission, storage and retrieval of medical documentation through the MEA/NEA Information Exchange Engine (IEE).
She describes basic practice management skills, the parts of the CMS-1500 form, and the steps of the claim process: setting up the doctor's schedule and reviewing the different appointment types; the patient's chart, medical documentation, and forms; patient and insurance information; the appointment, service, where it took place, who provided it, and the patient diagnosis; different types of coding systems used for billing and how a claim is formatted and filed; processing an allowed claim and types of reimbursement fees, including the explanation of benefits and what the American National Standards Institute reason codes mean; and claims that cannot be processed or denied claims, including appeals and patient balances.
The purpose of the workshop is to train a group of doctors and psychologists to conduct effective medical documentation of torture and abuse in Kyrgyzstan.
Case histories accompany medical documentation and keys to eliminating or controlling such phantom sounds.