Alias, An assumed name, Comorbidity, Preexisting condition that causes an increase in a patient's length of stay, Complication, A condition that arises after the beginning of a hospital stay that modifies the course of a patient's illness and/or treatment, Upcoding, Documentation of diagnoses and procedures that result in higher reimbursement, Advance directive, Legal document where patients provide instructions as to how they want to be treated in the event they become very ill and there is no realistic hope for recovery, Informed consent, Process of advising a patient about treatment options, History, Documents the patient's chief complaint, history of present illness, past/family/social history, and review of systems, Progress note, Contains statements related to the course of a patient's illness, response to treatment, and status at discharge, Autopsy, An examination of a body after death, Encounter, A professional contact between a patient and a provider who delivers services or is professionally responsible for services delivered to a patient
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Patient Record Documentation Guidelines
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