A Fordney Ch3
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| A medical record is considered | medical information and a health record
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| A medical report is a | permanent legal document and a part of the medical record
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| The key to substantiating procedure and diagnostic code selections for proper reimbursement is | supporting documentation in the medical record
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| The chronologic recording of pertinent facts and observations about the patient's health is known as | documentation
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| Reasons for documentation are | defense of a lawsuit and/or insurance carriers require accurate documentation that supports procedure and diagnostic codes
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| The SOAP in patient medical record charting may be defined as | S-subjective, O-objective, A-assessment, P-plan
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| 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
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| 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
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| 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
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| Levels of evaluation and management services are based on type(s) of physical examination that may be | problem focused
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| An expanded problem-focused examination is a/an | limited examination of the affected body area
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| 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
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| Varicella is the medical term for | chickenpox
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| Dyspnea is the medical term for | difficult breathing
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| Coryza is the medical term for | a cold
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| Alopecia is the medical term for | baldness
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| A diseased condition or state is known as | morbidity
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| Underlying disease or other conditions present at the time of the visit is known as | comorbidity
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| What does comorbidity mean | underlying diseases or other conditions present at the time of the visit
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| 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
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| 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
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| 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
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| When a discussion takes place with a patient concerning the risks and benefits of treatment options it is considered | counseling
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| Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the | right lower quadrant
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| Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as | intermediate
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| The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading | Simple
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| A review of patient records done before billing is submitted is called | prospective
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| Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime | exclusion from program participation is mandatory
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| 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
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| 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
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| Who may accept a subpoena | The prospective witness, or an authorized person
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| Preservation of medical records is governed by | state and local law
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| Records that must be retained indefinitely include | patients' medical records, x-ray films, and inactive patients' medical records
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| Provider who sends the patient for tests or treatment | referring physician
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| Provider whose opinion is requested by another physician about evaluation and management of a specific problem | consulting physician
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| Provider who is the medical staff member who is legally responsible for the care and treatment given to a patient | attending physician
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| Individual who directs the selection, preparation, or administration of tests, medications, or treatment | ordering physician
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| Provider who renders a service to a patient | treating or performing physician
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| Situation associated with the pain/symptom | context
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| Area of the body in which the symptom is occuring | location
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| When the pain/symptom occurs | timing
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| Character of the symptom/pain (burning, gnawing) | quality
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| How long the symptom/pain has been present and how long it lasts when the patient has it | duration
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| Symptom/pain and other changes that are noted when the symptom/pain occurs | associated signs and symptoms
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| Things done to make the symptom/pain worse or better | modifying factors
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| Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness | consultation
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| Transfer of the total care of a patient from one physician to another | referral
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| Providing similar services to the same patient by more than one physician on the same day | concurrent care
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| Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition | continuity of care
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| Discussion with a patient, family, or both about diagnostic results and instructions for treatment | counseling
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| Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician | critical care
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| Care provided during a life-threatening condition in the hospital emergency department | emergency
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| Degree of symptom and/or pain on a scale from 1 to 10 | severity
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Created by:
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