Match each definition to one of the following items.
-Synopsis of the events of a patient's hospital encounter
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers

Question

Quizplus · Accepted Answer

Discharge summary refers to the synopsis of the events of a patient's hospital encounter.

Answer: A
 Tabular List is a list of codes that represents different diagnoses, procedures, and related data elements.

Answer: B
 See also is a reference in coding books and manuals to direct the coder to another code or information source.

Answer: F
 ER refers to the Emergency Room where urgent medical care is provided for acute illnesses and injuries.

Answer: G
 Differential diagnosis is a process of determining a diagnosis by comparing and contrasting the clinical findings of the patient.

Answer: H
 Chief complaint refers to the main reason why a patient seeks medical attention.

Answer: I
 The first basic step in coding the principal diagnosis involves reviewing the medical record to identify the reason for hospitalization.

Answer: J
 Nonessential modifiers are additional words or phrases in a diagnosis statement that do not change the meaning of the diagnosis, but can provide additional information.

Note: There is no choice C or E in the given options.

Match Each Definition to One of the Following Items