I did this course last year, and, if I remember correctly, a single underline = Primary key, double underline = Foreign key.
If you look at the definition and the examples, you'll see that Patient_Num is the primary key for both Charges and Patient tables. Item_Code is your "link" to the Item table.
Somewhere in our notes (or the text book), there was definately an explaination about the single and double underline and about combined Primary keys. I don't have that with me, so, you'll have to go and search for those definitions yourself.
Good luck.
Reanie