Medical Documentation
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
sanzijessica
Popular Medical sets