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MedOfficeProcedures4
Medical Documentation
Question | Answer |
---|---|
What is documentation? | Chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports |
What is a constitutional component? | Vital signs, general appearance, and nutrition |
What is the procedure to correct a medical record? | Use a legal copy pen to draw one line through incorrect information. Write the correct information, date, and initial |
What is subjective information? | Complaints |
What is objective information? | Facts and findings |
What is the reason for a compliance program? | To reduce fraudulent insurance claims and to provide quality care to patients |
What is a consultation? | Services rendered by a physician whose opinion or advice is requested by another physician |
What is a referral? | Transfer of specific or total care from one physician to another |
Who are documenters? | All individuals providing health care |
What does SOAP stand for? | Subjective, objective, assessment, and plan |
What audit terminology should you avoid? | Negative, and WNL (within normal limits) |
What is an internal review? | Done before billing is submitted (within office) |
What is an external audit? | Done after claims have been billed (may be done by office or insurance company) |
What is medical necessity? | Medical services or procedures must be justified by patient's symptoms and diagnosis |
What is concurrent care? | Providing of similar service by more than one physician on the same day |
What is co-morbidity? | Underlying disease or other conditions present at the time of the visit |
What is a subpoena? | Requiring the appearance of a witness at a trial or other proceeding |