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Referral

Sending a patient to a provider of a different specialty for treatment beyond the initial practitioner's scope of practice.

Audit

Inspection.

Matrix

Format for establishing a time schedule for appointments.

Encounter Form

Also called superbills; a record of information obtained during a health care visit that designates what services and/or procedures are performed.

Electronic Health Records (EHR)

Interoperability of electronic medical records; an aggregate record of health-related information created by multiple health care organizations.

SOAP

A method of charting patient information that includes Subjective, Objective, Assessment, and Plan.

Subjective

Information supplied by the patient including history and chief complaint.

Real Time Adjudication (RTA)

Immediate and complete adjudication of a health care claim upon receipt by the payer.

Objective

Chronologic file commonly used for follow-up.

Progress Note

Record of the continuing progress and treatment of a patient.

Privacy Officer

Person designated to oversee maintenance of protected health information in a health care organization.

Indexing

System of cross-referencing information in office files for searchable data.

Continuity of Care

Delivery of services to a person without lapse or interruption in treatment.

Encoder

Software application for searching CPT, HCPCS, ICD codes, and Medicare coding guidelines.

Chronologic

Arrangement of events in order of occurrence.

CHEDDAR

Delivery of services without interruption to maintain health and treatment.

HL7 Protocols

Standard for exchanging information between medical applications.

Chief Complaint (C/C)

Main reason for a patient's visit noted in the medical record.

Transcription

Writing over from one book or medium into another.

Utilization

To use or make use of.

Flex Time

Practice of permitting work hours within a range of time.

Tickler File

Chronologic file used for follow-up methods.

History Physical Impression Plan (HPIP)

System for recording medical information similar to SOAP.