Final Review
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Why do we keep records? #1 | Legal Use. Medical records are legal documents and can be subpoenaed. They can be used in malpractice suits.
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| Why do we keep records? #2 | Medical records evaluate quality of treatment
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| Why do we keep records? #3 | Provide for continuity of care.
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| Why do we keep records? #4 | Allows for communication between provider and staff.
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| Why do we keep records? #5 | Documents the patient's original evaluation.
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| Why do we keep records? #6 | Reports any changes in the patient's condition
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| Golden Rule of Documentation? | If it didn't get documented it didn't happen.
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| Release of Information | Should not be done over the phone.
Should not be transmitted unless over a secure line or it is encrypted.
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| Ownership of records | In private practice where there is ONE physician: The physician owns the physical chart. In group practice, the clinic owns the physical chart. The PATIENT owns the information in the chart.
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| Correction of a record | Never use white out. Draw a single line through the error. Make the correction. Sign and date the correction.
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| Chart Status: Active | Patients currently being seen
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| Chart Status: Inactive | Patients not been seen recently (up to 3 yrs) (After 3 yrs, New Patient)
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| Chart Status: Closed | Deceased patients, Patients that won't be seen anymore (Moved, Fired, Etc.)
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| Abbreviations | Only use those accepted by facility. Standard Medical Abbreviations.
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| AMA Recommendations | Train Employees in HIPAA & Confidentiality. Conduct audits of employee movement through records. Prepare back up plan
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| Security | Don't open emails that you don't recognize the sender. Change passwords
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| Flow Sheets | Record ongoing measurement
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| POMR chart | Problem oriented medical record. Listed and assigned numbers.
Recognize component list: Database, problem list, treatment plan, progress notes
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| SOAP chart | S)ubjective Patient Info - What pt. tells you is worng
O)bjective clinical measurements - BP, weight, temp
A)ssessment/Diagnosis
P)lan for treatment
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| Late Documentation | Document note with current date but chart for late entry for date and time of occurrence.
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| Progress Notes | Documentation of every patient encounter. Including phone calls and prescription refills.
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| Advance Directive | Living Will
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| HIPAA Title 1 | Covers health insurance access and portability & renewal. Those who fall under are called covered entities. Covered entities are: Healthcare Workers, Insurance Cos., Clearinghouses. HIPAA officer: oversees all aspects of compliance
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| Demographic Info |
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| Narrative: | Paragraph indicating contact with patient
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| Diagnosis: | Disease or condition identified in a patient
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| Chronological Order: | Place in order of time (date) most recent
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| Referral: | Instruction to transfer a patient's care to a specialist.
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| Medical Impression: | Conclusions drawn by the physician from the interpretation of data
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| Health History Report: | Provides subjective data to assist in diagnosis.
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| Chief Complaint: | The problem that is causing the patient to seek medical treatment (in their own words). Found in the clinical section of the chart. Main reason foe the medical office visit.
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| Objective Symptom: | A symptom that can be observed by the examiner(or measured) i.e. temp, rash, BP, etc.
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| Subjective Symptom: | Symptom felt by the examiner, but not observed by examiner.
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| Physical Exam Report: | Report of a physician's objective findings.
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| Prognosis: | Probably course and outcome of a patient's condition.
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| Business Letters | Use only standard abbreviations
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| Clearinghouse | Entity that receives, reviews, sends and manages claims
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| Written correspondence |
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| How do you secure email? | With an encryption feature
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| How many formats for business letters? | 4 (clearinghouses, record classification, chief complaint, medical records)
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| Record Classification | Active, Inactive, Closed
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| Chief Complaint | Subjective
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| Patient registration -Administrative info | Collecting demographics does not include clinic info
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| Can we copy anything on the internet? | NO. Copywrite laws apply.
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