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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
The NPI is often a common denominator between various healthcare provider identifier numbers, such as CMS Certification Number [10] (CCN; formerly OSCAR number), Employer Identification Number, and PECOS Associate Control ID [11] (PAC ID). With an increasing number of publicly available datasets containing these identifiers, some organizations ...
This definition is sometimes stretched in the U.S. medical billing industry, where hospital corporations may blur the definitions of "admission" and "observation" because of reimbursement rules under which healthcare payors pay less for the care if an "admission" was involved. [2]
A DEA number (DEA Registration Number) is an identifier assigned to a health care provider (such as a physician, physician assistant, nurse practitioner, optometrist, podiatrist, dentist, or veterinarian) by the United States Drug Enforcement Administration allowing them to write prescriptions for controlled substances.
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
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The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.