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MIBC F3

A Fordney Ch3

QuestionAnswer
A medical record is considered medical information and a health record
A medical report is a permanent legal document and a part of the medical record
The key to substantiating procedure and diagnostic code selections for proper reimbursement is supporting documentation in the medical record
The chronologic recording of pertinent facts and observations about the patient's health is known as documentation
Reasons for documentation are defense of a lawsuit and/or insurance carriers require accurate documentation that supports procedure and diagnostic codes
The SOAP in patient medical record charting may be defined as S-subjective, O-objective, A-assessment, P-plan
When a patient fails to return for needed treatment, documentation should be made In the patient's medical record, the appointmant book and on the financial record or ledger card
How should an entry in a patient's medical record be corrected cross out the incorrect entry, substitute the correct information, date and initial the entry
A concise statement describing the symptom, problem, condition, dx, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as CC
Levels of evaluation and management services are based on type(s) of physical examination that may be problem focused
An expanded problem-focused examination is a/an limited examination of the affected body area
Official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the" final diagnosis, operative notes, discharge summaries
Varicella is the medical term for chickenpox
Dyspnea is the medical term for difficult breathing
Coryza is the medical term for a cold
Alopecia is the medical term for baldness
A diseased condition or state is known as morbidity
Underlying disease or other conditions present at the time of the visit is known as comorbidity
What does comorbidity mean underlying diseases or other conditions present at the time of the visit
A new patient is one who has not received any professional services from a physician who belongs to a group practice within the past 3 years
An established patient is one who has previously received professional services from a physician or another physician of the same specialty who belongs the the group within the past 3 yrs
In dealing with managed care plans, a referral is the transfer of the total or specific care of a patient from one physician to another or the term used when requesting an authorization for the patient to receive services elsewhere
When a discussion takes place with a patient concerning the risks and benefits of treatment options it is considered counseling
Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the right lower quadrant
Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as intermediate
The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading Simple
A review of patient records done before billing is submitted is called prospective
Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime exclusion from program participation is mandatory
Who may sign for disclosure of the medical record of a minor patient who is legally capable of consenting to medical treatment Only the minor patient
Which of the following cases should NOT use fax transmission Transmission of documents relating to information on sexually transmitted diseases. Any routine transmission of patient information. Transmission of documents relating to alcohol treatment
Who may accept a subpoena The prospective witness, or an authorized person
Preservation of medical records is governed by state and local law
Records that must be retained indefinitely include patients' medical records, x-ray films, and inactive patients' medical records
Provider who sends the patient for tests or treatment referring physician
Provider whose opinion is requested by another physician about evaluation and management of a specific problem consulting physician
Provider who is the medical staff member who is legally responsible for the care and treatment given to a patient attending physician
Individual who directs the selection, preparation, or administration of tests, medications, or treatment ordering physician
Provider who renders a service to a patient treating or performing physician
Situation associated with the pain/symptom context
Area of the body in which the symptom is occuring location
When the pain/symptom occurs timing
Character of the symptom/pain (burning, gnawing) quality
How long the symptom/pain has been present and how long it lasts when the patient has it duration
Symptom/pain and other changes that are noted when the symptom/pain occurs associated signs and symptoms
Things done to make the symptom/pain worse or better modifying factors
Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness consultation
Transfer of the total care of a patient from one physician to another referral
Providing similar services to the same patient by more than one physician on the same day concurrent care
Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition continuity of care
Discussion with a patient, family, or both about diagnostic results and instructions for treatment counseling
Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician critical care
Care provided during a life-threatening condition in the hospital emergency department emergency
Degree of symptom and/or pain on a scale from 1 to 10 severity
Created by: leemiller on 2005-12-04



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