Primary Response: Within the Discussion Board area, write 200–250 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. Be substantive and clear, and use examples to reinforce your ideas.

For this Discussion Board, please complete the following:

Using course materials and online resources, respond to the following scenario:

When a patient is seen in the emergency department (ED) of a hospital, that visit is documented in an ED Visit Note. The ED note must be brief but complete. This is because the physician and patient encounter in the ED is the basis for continued care (admission or follow-up) by providers outside of the ED. It is also important for coding and billing that the information be accurate and complete to obtain proper reimbursement. This is true for all health records and documentation.

Read the patient’s EHR ED Visit Note using this link. Then, complete the following:

  • Explain to the patient and her family in your own words (using layman’s terms) what each section (subjective, objective, assessment, and plan) of the ED Visit Note means.  
    • To do this, you will have to look up all of the bold terms and abbreviations in the EHR ED Visit Note.

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Medical Terminology Due 04.16.2021
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