Review of System
An inventory of the body system obtained through a series of questions that is used to identify signs or systems that the pt might be experiencing or has experienced
Is a criterion used by insurance companies, as well as federal programs such as medicare, when making decisions to limit or deny payment in which medical services or procedures must be justified by the pt's systems and diagnosis.
Is the providing of similar services to the same pt by more than one phy on the same day. (in hospital visit)
If a professional claim is filed, a pt's good documentation helps establish a strong defense.
An age-appropriate review of past and current activities of pt. (smoke, alcohol consumtion)
What is considared an established patient?
One who has recieved professional services from the physician of the same speciality who belongs to the same group practice within the past 3 years.
What is considared a new patient?
One who has not recieved any professional service the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
How is documentation made when a patient fails to return for needed treatment?
Record a pt's failure to return for needed treatment by noting it in the health record, in the appointment book, and on the financial record or ledger card.
Follow-up with a telephone call or send a letter to the pt advising him/her that further treatment is indicated.
Name two reasons for documentation?
1. Defence of professional liability claim
2. Insurance carriers require accurate documentation
The SOAP method in pt medical record charting is defined as?
Subjective, Objective, Assessment, Treatment plan.