Insurance Handbook - Ch. 4 Medical Documentation

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What is a health record?

written or graphic information documenting facts and events during the rendering of patient care.

What is a paper-based medical report?

it is part of the health record and is a permanent legal document that formally states the outcomes of the patient's examination or treatment in letter or report form.

What is the key to substantiating procedure and diagnostic code selection for reimburement?

is supporting documentation in the health record.

Who are documenters?

all individuals providing health care services.

What do documenters do?

they chonologically record pertinent facts and observations about the patient's health.

What is documentation?

it is the process of charting. It may be handwritten, dicatated and transcribed,, or downloaded from a personal digital assistant (PDA) using an electronic template.

Define attending physician

the hospital staff member who is legally responsile for the care and treatment given to a patient.

Definf consulting physician

a provider whose opinion or advice regarding evaluation or management of a specific problem is requested by antoher physician.

Define ordering physician

is the inidividual in the hospital directing the selection, preparation, or administration of tests, medication, or treatment.

Define referring physician

is a provider who sends the patient for tests or treatment.

Define treating or performing physician

is the provider who renders a service to a patient

What is the first reason for legible documentation?

for enforcement of medical record-keeping rules by insurance carriers who require accurate documentation that supports procedure and diagnostic codes.

What is the second reason for legible documentation?

as a defense in a professional liaility claim.

What is SOAP?

it is a charting procedure methose used for documenting progress notes.

What does the "S" in SOAP stand for?

Subjective statements of symptoms and complaints = in the patient's own words. It is the Chief Complain (CC) or reason for the encounter.

What does the "O" in SOAP stand for?

Objective facts and findings. It includes data from physical exams, x-rays, and laboratory & diagnostic test results.

What does the "A" in SOAP stand for?

Assessment of subjective and objective findings. It is the medical decision making (putting all facts together to obtain a diagnosis).

What does the "P" in SOAP stand for?

Plan of treatment. It is documenting a care plan to be put into action (recommendations, instructions, further testing, medication).

What do you do if a patient fails to return for needed treatment?

you note the failure to return in the health record, appointment book, and on the financial record or ledger card.

How do you correct an incorrect entry on a patient's record?

use a permanent, non-water coluble ink pen (legal copy pen) to cross out the incorrect information. Mark it with a single line and write the correct information. Then date and initial the entry.

History of present illness - 1) Define Location

the area of the body where the symptom is occuring.

History of present illness - 2) Define Quality

the character of the symptom/pain (burning, gnawing, stabbing, etc.)

History of present illness - 3) Define Severity

the degree of symptom or pain on a scale from 1 to 10 (severe, slight, and persistent).

History of present illness - 4) Define Duration

is how long the symptom/pain has been present and how long it lasts when the patient has it.

History of present illness - 5) Define Timing

is when the pain/symptom occurs (morning, evening, after meals etc.).

History of present illness - 6) Define Context

is the situation associated with the pain/symptom (with big meals, with activity, etc.).

History of present illness - 7) Define Modifying Factors

are the things done to make the symptoms/pain better or worse.

History of present illness - 8) Define Associated Signs and Symptoms

the symptoms/pain and other things that happen when the original symptoms/pains occur (chest pain leads to shortness of breath).

What is morbidity?

is a diseased condition or state.

Define comorbidity

means the underlying disease or other conditions present at the time of the visit.

What is a consultation?

are services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or a suspected problem.

What is a referral?

is the transfer or the total or specific care of a patient from one physician to another for known problems. It is NOT a consultation.

Define Concurrent care

is the providing of similar services (ex. hospital visits) to the same patient by more than one physician on the same day.

Define Continuity of Care

a patient who has received treatment for a condition and is then reffered by the physician to a second physician for treatment for the same condition.

Define Critical Care

intensive care provided in a variety of acute life-threatening conditions requiring constant "full attention" by a physician.

What is emergency care?

is care provided to acutely ill patients and may or may not involve organ system failure but does require immediate medical attention.

What is counseling?

is a discussion with a patient, family, or both concerning one or more of the following: Diagnostic results, impressions, or recommended diagnostic studies; prognosis; risks and benefits of treatment options.

What does the Official American Hospital Association policy state about abbreviations?

"abbreviations should be totally eliminated from the more vital sections of the health record, such as final diagnosis, operative notes, discharge summaries, and descriptions of special procedures.

What do intermediate lacerations require?

layered closure of one or more of the deeper layers of the skin and tissues.

What is the first type of internal review?

the prospective review

What is the prospective review?

also termed prebilling audit or review which is done before billing is submitted.

What does the American Health Information Management Association (AHIMA) advise on fax machines?

that fax machines should not be used for routine transmission of patient information.

What information should not be faxed?

documents containing information on sexually transmitted diseases, drug or alcohol treatment, or human immunodeficiency virus (HIV) status.

What is the supeona process for delivery?

a subpeona must be personally served or handed to the prospective witness or keepr of the health records.

What is personal service?

the acceptance of a document by someone authorized to accept it.

Who governs prevention of health records?

state and local laws

The enactment of the Federal False Claims Act established what?

that proof materials for the establishment of evidence (such as: x-ray films, lab reports, and pathology specimens) should be kept indefinitely in case of legal inquiry.

How can you indentify the main terms in the CPT manual?

they are in bold pront and are flushed with the left margin of each column.

What is the Anesthesia section range?

00100 - 01999

What is the Radiology section range?

70010 - 79999

What is the Pathology and Laboratory section range?

80047 - 89398

What is the Medicine section range?

90281-99607

In the CPT manual index what is "see"?

"see" is a cross-reference term that directs you to another term(s). See indicates that the correct code will be found elsewhere.

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