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CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
For example, if a clinical coder or Health Information Manager was extracting data from a medical record in which the principal diagnoses was unclear due to illegible handwriting, the health professional would have to contact the physician responsible for documenting the diagnoses in order to correctly assign the code.
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
Examples: ICD-9-CM, ICD-10, ICD-11 [1] Procedural codes. They are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals. Examples: CPT, HCPCS, ICPM, ICHI; Pharmaceutical codes. Are used to identify medications; Examples: ATC, NDC, ICD-11; Topographical codes
v70–v82 Persons without reported diagnosis encountered during examination and investigation of individuals and populations V70 General medical examination; V71 Observation and evaluation for suspected conditions not found; V72 Special investigations and examinations; V73 Special screening examination for viral and chlamydial diseases
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
List of ICD-9 codes 001–139: infectious and parasitic diseases; List of ICD-9 codes 140–239: neoplasms; List of ICD-9 codes 240–279: endocrine, nutritional and metabolic diseases, and immunity disorders; List of ICD-9 codes 280–289: diseases of the blood and blood-forming organs; List of ICD-9 codes 290–319: mental disorders
The Systematized Nomenclature of Medicine (SNOMED) is a systematic, computer-processable collection of medical terms, in human and veterinary medicine, to provide codes, terms, synonyms and definitions which cover anatomy, diseases, findings, procedures, microorganisms, substances, etc. It allows a consistent way to index, store, retrieve, and ...