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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 ...
(4000F–4563F) Therapeutic, preventive or other interventions (5005F–5250F) Follow-up or other outcomes (6005F–6150F) Patient safety (7010F–7025F) Structural measures (9001F–9007F) Non-measure claims-based reporting; CPT II codes are billed in the procedure code field, just as CPT Category I codes are billed.
Office Open XML (OOXML) format was introduced with Microsoft Office 2007 and became the default format of Microsoft Word ever since. Pertaining file extensions include:.docx – Word document.docm – Word macro-enabled document; same as docx, but may contain macros and scripts.dotx – Word template.dotm – Word macro-enabled template; same ...
The term template, when used in the context of word processing software, refers to a sample document that has already some details in place; those can (that is added/completed, removed or changed, differently from a fill-in-the-blank of the approach as in a form) either by hand or through an automated iterative process, such as with a software assistant.
The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases. This repository of information about a single patient is generated by health care professionals as a direct result of interaction with a patient or with ...
Microsoft Word allows creating both layout and content templates. A layout template is a style guide for the file styles. It usually contains a chapter which explains how to use the styles within the documents. A content template is a document which provides a table of contents. It might be modified to correspond to the user's needs.
Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1]
Corrective and preventive action (CAPA or simply corrective action) consists of improvements to an organization's processes taken to eliminate causes of non-conformities or other undesirable situations. It is usually a set of actions, laws or regulations required by an organization to take in manufacturing, documentation, procedures, or systems ...