Group of patient medical records maintained by the physician. Each record documents the patient’s treatment in progress notes, diagnostic and therapeutic procedures or tests and their results, findings and conclusions from special examinations, correspondence from other providers, specialists, or consultants, medications, surgical operations, and other reports pertinent to the patient’s care.

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.

1. Scheme to enroll in a managed care plan only those individuals who are healthy and excluding individuals who have existing health problems. 2. Situation in which a coder chooses the easier cases to code and leaves behind the more difficult ones. This situation also may occur with transcription, where one transcriptionist may skip a more difficult-to-understand dictator for the dictation of another physician who enunciates.

Patient’s statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.