Medical Terminology & Documentation Flashcards

A worker's record lists 'CTS, R > L.' What condition is documented?

Answer: Carpal tunnel syndrome, right worse than left

CTS is carpal tunnel syndrome, and 'R > L' indicates the right side is more affected than the left.

Which term describes a joint position where the palm faces upward?

Answer: Supination

Supination rotates the forearm so the palm faces up, while pronation turns it down.

An FCE report uses the term 'coefficient of variation' (CV) for repeated grip trials. What is it used to assess?

Answer: Consistency of effort across repeated trials

CV measures variability among repeated trials, and a low CV generally suggests consistent effort.

A physician documents 'hypertonicity of the upper trapezius.' What does this indicate?

Answer: Increased muscle tone or tightness

Hypertonicity means abnormally increased muscle tone, often palpable as tightness or spasm.

Under HIPAA, which practice best protects an injured worker's records shared with an employer during a return-to-work process?

Answer: Share only the minimum necessary information, such as functional abilities and restrictions, with proper authorization

The minimum necessary standard limits disclosure to information needed for the purpose, such as work restrictions rather than full diagnoses.

A note states the worker has 'atrophy of the right quadriceps.' What finding is described?

Answer: Decrease in muscle size of the front thigh

Atrophy is wasting or decrease in muscle bulk, often from disuse or nerve injury.

In an ICD-10-CM coded workers' compensation claim, what does the 7th character 'D' typically indicate for an injury code?

Answer: Subsequent encounter

For most injury codes, 'A' is initial encounter, 'D' is subsequent encounter, and 'S' is sequela.