| A | B |
|---|
| Health Record | The principal repository for data about the healthcare services provided to a patient. |
| Operative Report | It describes the surgical procedure performed on the patient. |
| Consultation Report | It documents the clinical opinion of a physician other than the primary or attending physician. |
| Discharge Summary | It is a concise account of the patient’s illness, course of treatment, response to treatment and condition at the time the patient is discharged. |
| Autopsy Report | Is a description of the exam of the patient’s body after he/she has died. |
| UHDDS | Their intent is to list and define a set of common, uniform data elements. |
| Ambulatory Care | It includes medical and surgical care that is provided to patients who return to their homes on the same day the care is provided. |
| Data | It represents basic facts and measurements. |
| Information | It refers to the data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for specific purposes. |
| CPT-4 Manual | It is the official list of procedures was developed by the American Medical Association. |
| Procedure Code | It tells what is done for/to the patient to provide treatment. |
| ICD-9-CM Manual | It is the official list of diseases developed by the World Health Organization. |
| Diagnosis Code | It tells what is wrong with the patient/the patient’s illness. |
