50 terms

Test Review 115-2

T/F- Disability income policies do not provide medical expense benefits?
T/F- Problem-Focused exam is more complex than a detailed exam?
T/F- Consultation may take place in a home, office, hospital, or extended care facility?
T/F- A referral is the same as a consultattion?
T/F- When the physician provided critical care in the hospital emergency dept. it is billed as emergency care?
T/F- In an industrial case, MD's office may collect from the Pt. all amounts not covered by the workers comp. fee schedule?
Disability income is available from?
Private Insurance Co. (individual policy), Employer sponsored plans (group policy), Government and State
When an illness or injury prevents an insured person from performing one more of the functions of their regular job, the disability is called?
Residual or Partial disability
Provisions written into the insurance contract denying coverage or limiting the scope of coverage are called?
In 1956 Congress established a program under Title II of the Social Security Act for long term disability known as?
Social Security Disability Insurance(SSDI)
The chronologic recording of pertinent facts and observations about the Pt. health is known as?
Documentation and Charting
The SOAP in patients medical record charting may be defined as?
Subject, Objective, Assessment, Plan
When a Pt. fails to return for needed treatment, documentation should be made?
In the Pt.'s health record, in the appointment book, and on the financial record or ledger card
How should an entry in a Pt. medical record be corrected?
Use a permanent ink pen, Mark it with a single line and write the correct informationm then date and initial the entry
Official American Hospital Assosiation policy states that abbreviations should be totally eliminated from the more crital sections of the record, such as the ?
Final diagnosis, operative notes, discharge summaries, and descriptions of special procedure
A disease condition or state is known as?
In dealing with manage care plans, a referral is?
Requesting an authorization for a Pt. to recieve service elsewhere and transfer of total care
Your MD has been to the hospital providing constant bedside attention and treating a Pt in respiratory failure, These services are considered?
Critical Care
When a discussion takes place with a Pt., family or both concerning the risks and benefits of treatment options, it is considered?
Which of the following cases should NOT use fax transmission unless absolutely necessary?
D- All the above Psychiatric records and Psychotherapy note / documents that contain sexual transmitted diseases, drug, alcohol treatment, HIV/ Pt. information
The statue of worker's comp. law falls under?
Federal and State compensation laws
The reason for workers comp. law is?
D- All the above
State compensation benefits include?
Medical care, disability income, death benefits
OSHA stands for?
Occupational Safety and Health Administration
A proceeding in which an attorney asks a witness questions regarding a case and the witness answers under oath but not in open court is known as a/an?
In a workers comp. case, the contract and financial responsibility exist between the?
Physician and Insurance company and or state program
A wit requiring the appearance of a witness at a trial or other proceeding is known as an?
An external audit is conducted by?
Medicare Representative or Insurance carrier
The type of internal review conducted before billing is submitted is called?
Prospective review
A physicaian wishing to adapt to standardized documentation guidelines may choose between?
1995-1997 guild lines
The second-injury fund was designed to?
Meet problem arising when an employee has a preexisting injury or condition and is subsequently injured at work, and encourage hiring of the physically handicapped
Which of the following would qualify as an occupational illness or disease?
D- All above : inhalation, absorption, ingestion, or direct contact: berylliosis, anthracosilicosis, radiation disabilitym loss of hearing, cumulative trauma, and repetitive motion illness
The Longshoremen's and Harbor workers compensation Act provides benefits to?
Private or Public employees engaged in Maritime work nationwide
Vacational rehabilitation may include?
D- All the above
A lien works to the physicain's advantage in which of the following ways?
Insures payment from previous rendered medical service when the attorney and Pt. have reached a settlement
A woman is injured in a motor vehical while running a work-ralated errand during her lunch break. The worker's comp. insurance carrier adjusts the claim but then encourages tthe woman to get an attorney and sue the driver who hit her car after running a stop light. This is an example of?
Third party subrogation
With regards to the wrist, which of the following would be part of determning the Pt. range of motion?
Pronation and Supination
For documentation purposes, which of the following statements is true whenu using an eponym as opposed to the comparable medical term?
Should not be used when a comparable anatomic term can be used: Thromboangitis obliterans instead of burger's disease
Amened chart notes must be labeled?
Addendum or Late entry
The abdomen is divided into four quadrants and _____ regions?
If state of the art instruments or equipment are used in a surgical procedure, documentation should include the instrument or equipment as well as the ?
Time spent using it
Where it hurts
Character of the symptom/pain (burning,stabbing, gnawing)
Degree of symptom or pain on a scale of 1 to 19 or sever, slight persistent
How long the symptom/pain has been present and how long it last
When the pain/symptom occurs (morning,evening, after meals)
The situation associated with the pain/symptom (dairy products, big meals, activity)
Modifiying factors?
Things done to make the symptom/pain worse or better (eating spicy food)
Associated signs and symptoms?
The symptom/pain and other things that happen when the symptom/pain occurs (chest pain leads to shortness of breath)
In faxing a Pt. health record to a consulting pyhsician, you would?
Never include Pt.'s financial information