Reference page developed by a medical practice that acts as a shortcut to locating diagnostic codes for conditions commonly seen by a physician specialist. See encounter form.

Document that accompanies an explanation of benefits from a third-party payer that may be detached and deposited in a bank account. Sometimes referred to as a payment voucher. Also see explanation of benefits (EOB) and remittance advice (RA).

One of a standard style of charting (documenting) procedures for progress notes in patient’s medical records. This acronym may be interpreted as follows: C = chief complaint stated by the patient as the main reason for seeing the doctor; usually a subjective statement. H = history of the present illness and includes social history and physical symptoms, as well as contributing factors. E = examination performed by the physician. D = details or list of complaints and problems. D = drugs and dosages of the current medications the patient is taking. A = assessment that includes the diagnosis process and the impression (diagnosis) made by the physician. R = return visit information or referral to specialists for additional tests. Also see SOAP.