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Medical Documentation

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
Created by: sanzijessica