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2. Medical billing - Wikipedia

   en.wikipedia.org/wiki/Medical_billing

   Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.

3. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   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 ...

4. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

5. Consolidated Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Consolidated_Clinical...

   Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...

6. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.

7. Current Procedural Terminology - Wikipedia

   en.wikipedia.org/wiki/Current_Procedural_Terminology

   As the AMA decided in April 1960, the Current Medical Terminology (CMT) handbook was first published in June 1962 – 1963 to standardize terminology of the Standard Nomenclature of Diseases and Operations (SNDO) and International Classification of Diseases (ICD), and for the analysis of patient records, and was aided by an IBM computer. [22]