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  1. Referral: sending a patient to a provider of a different specialty for treatment beyond the scope of practice for the initial practitioner.

  2. Audit: inspection

  3. Matrix: format for establishing a time schedule for appointments.

  4. Encounter Form: also called superbills; a record of information obtained during a health care visit, usually a preprinted document, that designates what services and/or procedures are performed and at what level of acuity those services should be billed. Also called a charge slip; lists the procedures performed in that medical office, with their respective codes (seeFigure 25–9).

  5. Electronic Health Records (EHR): refers to the interoperability of electronic medical records, or the ability to share medical records with other health care facilities; (2) aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care (Ch 21).

  6. Subjective, Objective, Assessment, and Plan (SOAP):

  7. Dictation:

  8. Subjective: 1) when referring to charting, information is supplied by the patient and includes routine information about the patient, past personal and medical history, family history, and chief complaint (Ch 23); (2) relating to the person who is thinking, saying, or doing something; personal; of a disease symptom, felt by the individual but not perceptible to others (Ch 32).

  9. Real Time Adjudication (RTA): refers to the immediate and complete adjudication of a health care claim upon receipt by the payer from a provider. Adjudication is the final determination of the issues involving settlement of an insurance claim, also known as a claim settlement.

  10. Objective: chronologic file commonly used as a follow-up method for a particular date.

  11. Progress Note: record of the continuing progress and treatment of a patient

  12. Privacy Officer: the person designated by a health care organization, whether hospital system or private practice, who handles and oversees the maintenance of protected health information.

  13. Medicare Promoting Interoperability (PI) Program:

  14. Indexing: a system of cross-referencing information contained in office files so that the data may be searched using different characteristics as the query term; the second step in filing.

  15. Continuity of Care: the delivery of services provided to a person that proceeds without a lapse or interruption, with the intended purpose of maintaining a level of health and treatment.

  16. Encoder: software application that allows searching or browsing within CPT, HCPCS, ICD-9, and ICD-10 code sets, and Medicare coding guidelines.

  17. Chronologic: the arrangement of events, dates, and so on in order of occurrence.

  18. CHEDDAR: the delivery of services provided to a person that proceeds without a lapse or interruption, with the intended purpose of maintaining a level of health and treatment.

  19. HL7 Protocols: Health Level Seven protocol, the standard for exchanging information between medical applications.

  20. Chief Complaint (C/C): noted in the patient’s medical record as the main reason for the patient’s visit.

  21. Transcription: writing over from one book or medium into another; typing in full in ordinary letters.

  22. Utilization: to use or make use of.

  23. Flex Time: refers to the practice of permitting work hours within a range of time.

  24. Tickler File: a chronologic file commonly used as a follow-up method for a particular date

  25. History Physical Impression Plan (HPIP): a similar system to SOAP of recording medical information about patients is the history physical impression plan (HPIP) method