Frequently Used Medical Terms in In-patient DRG coding

Anti-inflammatory: Reduces swelling, pain, and soreness.

Body Mass Index (BMI): Body fat measurement based on height and weight.

Biopsy: A tissue sample for testing purposes.

Comminuted fracture: Broken bone that shatters into many pieces

Hypotension: Low blood pressure

Hypertension: High blood pressure

Lesion: Wound, sore, or cut

Benign: Non-cancerous

Malignant: Cancerous

Noninvasive: Non-surgical (No instrument to enter the body)

Inpatient: Plan to stay overnight for one or more days

In remission: Disease is not getting worse; not to be confused with being cured

Membrane: Thin layer of tissue that serves as a covering or lining or connection between two structures

Acute: Suddenly happening, but shorter duration (e.g., acute illness)

Angina: Pain in the chest related to the heart that comes and goes

Cellulitis: Inflamed or infected tissue beneath the skin

Compound fracture: Broken bone that protrudes through the skin

Epidermis: Outermost layer of skin

Edema: Swelling

Embolism: Blood clot

Sutures: Stitches

Polyp: Mass or growth of thin tissue

EHR: Electronic Health Record.

EMR: Electronic Medical Record.

OP Note: Descriptive note how the surgery has been performed. Illustrates how the surgeon entered the body (Laparoscopic or Open), body part operated, blood vessels ligated, instruments used(Hardware, tubings, catheters), body part removed or treated, type of sutures used etc.. 

ED Note: Emergency department note (The patient's first encounter to the hospital, where in-patient entry starts if required)

Lab Data: Logs all the tests performed on a patient while he/she stays in the hospital on daily basis.

Radiology Report: Important part of in-patient medical record. Contains information related to fractures, x-rays, Ultrasound, CT-scan, MRI, MRA. It also shows implants (Pacemaker, Stents, AICD, artificial body parts like joints, rods) central lines and tubes (PICC Line, Arterial lines, Endotracheal tube).

It also gives information of vital organs without the need to enter the body surgically.

Progress Notes: Records and represents the progression of health or condition of an admitted patient to the hospital.

Consult Notes: Records logged by the consultants (specialists) while the patient is admitted.

Query: Doubts raised by the In-patient Medical Coder to the treating physician to get clarification on inappropriate, insufficient  data.

                      (Let's discuss about !!!QUERIES??? in detail  in separate post)

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