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  2. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The CCC System uses a five-character structure to code the two terminologies: (1) CCC of Nursing Diagnoses and Outcomes and (2) CCC of Nursing Interventions and Actions. The CCC coding structure is paced on the format of the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision: Volume 1, WHO, 1992.

  3. Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Clinical_Document_Architecture

    The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts. [citation needed]

  4. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    The process begins when a physician documents a patient's visit, including the diagnoses, treatments, and prescribed medications or recommended procedures. [4] This information is translated into standardized codes through medical coding, using the appropriate coding systems such as ICD-10-CM and Current Procedural Terminology (CPT). A medical ...

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded.

  6. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.

  7. Ambulatory care - Wikipedia

    en.wikipedia.org/wiki/Ambulatory_care

    Many medical investigations and treatments for acute and chronic illnesses and preventive health care can be performed on an ambulatory basis, including minor surgical and medical procedures, most types of dental services, dermatology services, and many types of diagnostic procedures (e.g. blood tests, X-rays, endoscopy and biopsy procedures of ...

  8. Medical Expenditure Panel Survey - Wikipedia

    en.wikipedia.org/wiki/Medical_Expenditure_Panel...

    In addition to the general event visit information, this file includes certain details about any preventive services, tests, and vaccinations received. [20] The Home Health Visits files (released annually in August) – This file contains one record for each time that a certified home health medical practitioner visits a sampled individual.

  9. Doctor's visit - Wikipedia

    en.wikipedia.org/wiki/Doctor's_visit

    A doctor meeting with her patient in Egypt. Doctors develop a close relationship with their patients in order to build trust and better diagnose and treat disease.. A doctor's visit, also known as a physician office visit or a consultation, or a ward round in an inpatient care context, is a meeting between a patient with a physician to get health advice or treatment plan for a symptom or ...

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