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Wkbk Chap 4
Mod 2 Wkbk Chap 4 Medical Documentation
| Question | Answer |
|---|---|
| Written or graphic information about patient care is termed a/an | health or medical record |
| Written or dictated to record chronological facts and observations about a patient's health is called | Documentation |
| Performance of services or procedures consistent with the dx, done with standards of good medical practice and a proper level of care given in the appropriate setting is known as | medical necessity |
| List of all staff members names, job titles, signatures and their initial is known as | signature log |
| How should an insurance biller correct an error on a patient's record? | use a permanent ink pen to cross out with one line the incorrect entry, write in the correct information, date and initial |
| Name the six documentation components of a patients history | 1. Chief complain 2. HPI 3. ROS 4. Past hx 5. Family hx 6. Social hx |
| Review of systems | An inventory of body systems by documenting responses to questions about symptoms that a patient has experienced |
| New patient | One who has not been received any services from the doctor or another doctor of the same specialty in the same group within the past 3 years |
| Established | a person who has received services from a doctor or another doctor of the same specialty or in the same group within the past 3 years |
| Consultation | Services rendered by a physician whose opinion or advice is requested by another physician |
| Referral | the transfer of the total or specific care of a patient from one doctor to another for a known problem |
| Two physicians see the same patient on the same day for different problems - this medical care is called | concurrent care |
| Medical care for a patient who has received treatment for an illness and is referred to a second physician for treatment of the same condition is a situation called | Continuity of care |
| If a fax is misdirected what should you do? | Either telephone the party faxed or complete a misdirected fax form |
| # of years to keep computerized payroll records is | 7 |
| # of years to keep an insurance claim on a Medicare patient | 7 |
| # of years to keep the medical record of a deceased patient | 5 |
| How long should active patient records be kept? | Indefinatly |
| How long should phone records be kept? | Indefinately |
| Treating or performing physician | Renders a service to a patient |
| Ordering Physician | directs selection, preparation and administration of tests, medication or treatment |
| Attending physician | legally responsible for the care and treatment given to a patient |
| Consulting physician | gives an opinion regarding a specific problem that is requested by another doctor |
| Referring physician | sends the patient for tests or treatment or to another doctor for consultatiion |
| Primary care physician | oversees care of patients in managed care plans and refers patients to see specialists when needed |
| Teaching physician | responsible for training and supervising medical students |
| Resident physician | performs one or more years of training in a specialty area while working at a hospital |
| During the performance of an external audit to review a medical practices health records, the system used to show deficiencies in documentation is called | point system |
| The SOAP style of documentatiion that a doctor uses to chart a patients progress in the health record is called | subjective, objective, assessment and plan |
| Physical examination of a patient by a physician is | objective |
| Health care management process after doing a history and physical exam that result in a plan of treatment is called | medical decision making |
| underlying disease or other conditions present at the time of the patients office visit is | comorbidity |
Created by:
mpeoples