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Medical Documents

Horizontales
Also called chart notes. Provider’s formal or informal notes about presenting problem. Physical finding’s, and plan for treatment for a patient examined in the office, clinic, acute care center or emergency department.
Medical report that chronicles the details of a surgical procedure.
Document that reports the findings and advice of another provider.
Precess to provide accurate, complete, consistent healthcare documentation in a timely manner while making every reasonable effort to resolve inconsistencies, inaccuracies, risk management and other problems.
Verticales
Confidential information that may only be communicated with the patient’s permission or by court order.
Viewing specimens with the naked eye
Reports such as history and physical examinations that should be complete within 24 hours.
Inquiries about the system directly related to the problems identified in the history of present illness
Medical reports that document the hospitalization history of a patient.
“Chief complaint”
The practice of contracting with a service outside of the clinic or hospital t a company at a lower cost and with a faster turnaround time.
(Also called progress notes) a provider’s formal or informal notes about presenting problem, physical findings, and plan for treatment for a patient examined in the office, clinic, acute care center, or emergency department.
A medical report requested of medical transcription that should be returned within 2-4 hours.
Method of identifying a blank space or a question regarding dictator’s meaning by attaching a note or marker to indicate the question.