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  • Referral: Sending a patient to another doctor for special care.

  • Audit: A review or check of records to make sure everything is correct.

  • Matrix: A schedule layout showing available appointment times.

  • Encounter Form: A form used during a visit to list services and charges.

  • Electronic Health Records (EHR): Digital records of a patient’s health that can be shared between clinics.

  • SOAP: A way to write medical notes:

    • Subjective (what the patient says),

    • Objective (what the doctor observes),

    • Assessment (diagnosis),

    • Plan (treatment).

  • Dictation: Speaking medical notes out loud to be typed later.

  • Subjective: Information from the patient, like how they feel.

  • Real Time Adjudication (RTA): Instant decision on an insurance claim.

  • Objective: Facts the doctor can measure or see, like temperature.

  • Progress Note: Notes about how a patient is doing over time.

  • Privacy Officer: Person who protects patient health information.

  • Medicare Promoting Interoperability (PI) Program: A program to help doctors share patient info safely and easily.

  • Indexing: Organizing files so they’re easy to find later.

  • Continuity of Care: Ongoing care without gaps or delays.

  • Encoder: Software that helps find medical billing codes.

  • Chronologic: In time order, from earliest to latest.

  • CHEDDAR: A way to write medical notes using these parts:

    • Chief Complaint, History, Examination, Details, Drugs, Assessment, Return visit.

  • HL7 Protocols: Rules for sharing health info between computer systems.

  • Chief Complaint (C/C): The main reason the patient came in.

  • Transcription: Typing up spoken medical notes.

  • Utilization: Using something, like a service or resource.

  • Flex Time: Flexible work hours that can change day to day.

  • Tickler File: A reminder system organized by date.

  • HPIP: Another way to write medical notes:

    • History, Physical exam, Impression (diagnosis), Plan.