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FBLA Health Care Administration

Terms in this set (1314)

1. The health record should be accurate, complete (detailed), and legible.
2. Documentation of each patient encounter includes or provide reference to following:
a. chief complaint or reason for encounter
b. relevant history
c. physical examination
d. findings
e. prior diagnostic test results
f. assessment, clinical impression, or diagnosis
g. plan for care
h. date and eligible identity of the health care professional
3. The reason for encounter stated
4. Past and present diagnoses
5. Appropriate health risk factors should be identified
6. The patient's progress, response to and changes to treatment, planned follow-up care and instructions and diagnosis should be documented.
7. Patient refusal to follow medical advise
8. Procedure and diagnostic codes reported on the insurance claim form or billing statement supported by documentation.
9. Confidentiality of health record maintained
10. Each chart entry dated and signed
11. Standardized charting procedures for progress notes. Use either SOAP or CHEDDAR styles or narriative or detailed descriptive style. Must be detailed enough to support current documentation requirements.
12. Treatment plans written and consistent with working dx.
13. medications prescribed and taken, listed
14. request for or need for consultation must be documented. Include: consultant's opinion, services ordered documented, and communicated to requesting physician.- see pg 96 for additional
Four R's: requesting, render, report, reason, (and possibly return"
15. Record patient's fialture to return for needed treatment, in Heath record, appointment book, financial reocrd or ledger, follow telephone call or letter to patient indicated
16. How to correct documentation "errors". see pg 96.
Never delete or or key over incorrect data. or flag it as amended or obsolete and create an addendum typed as a separate document or for a chart note inserted below in the next space availabe. paper charting - initial correction. never erase, white, out or use self adhesive paper over any information record on a patient record.
17. Document all lab tests, physcian intials report as read.
18. Ask physician for approval for differnt code before transmitting claims
19. Retain all records (until positive no longer necessary by conforming to federal and state laws, and physician wishes)