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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

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