Chap 6 Flashcards
(31 cards)
What do you do if a patient is non compliant?
You must document this
What are active problems?
Active problems include current or chronic conditions that require ongoing management or further workup
What must be documented with each problem?
The date of onset and the International Classification of Diseases, 9th Revision (ICD-9)
What are inactive problems?
Inactive problems are those that occurred in the past but are now resolved and can be either medical or surgical.
Upon receiving a hospital discharge summary what do you need to do?
any newly diagnosed conditions or surgeries should be added to the list.
What is put on the medication list?
All prescription and nonprescription medications should be listed. It is important to include herbal products, vitamins, minerals, dietary supplements, or other regularly used over-the-counter (OTC) products.
What does a medication list help with?
A comprehensive list will alert the provider to possible drug-drug or drug-herb interactions. It will also help to avoid duplication
What should be included for each medication?
The list should include the name of the medication, indication, strength, and dosing directions
What do you do if a med is discontinued?
When a medication is discontinued, it is helpful to indicate the date and reason why directly on the medication list.
Should medication allergies be listed on the medication chart?
YES, as well as specific reaction
When do you use a flow sheet?
Many chronic medical conditions require regular monitoring of certain parameters. The frequency of monitoring depends on whether the patient is stable or unstable.
Use it for labs and treatments!!
What are some unintentional barriers to compliance?
Some unintentional barriers to compliance may be the patient’s culture, language, religious practices or beliefs, or socioeconomic factors.
What could a patients failure to improve mean?
Failure to improve could mean that the patient has not been correctly diagnosed, the correct treatment has not been initiated, or the patient has not been compliant with the recommended treatment.
Where do we document noncompliance?
“Noncompliance” should be documented in the assessment and on the problem list.
What do we have to document with a noncompliant patient?
Any advice or education provided should be documented in the plan
What is the minimum you should document for billing information?
At a minimum, you should document the patient’s full legal name, address, telephone number, and date of birth.
What should we not use to identify the patient?
SSN
Where do you keep billing information?
It is generally recommended that billing information and any correspondence regarding billing and payment issues be kept separate from clinical data.
How are lab and imaging tests filed?
chronologically, most recent first
Why is it important for the referring doctor to say why the pt is being referred?
so that the consulting provider knows whether to provide an opinion only or to manage the patient’s condition actively.
In order to send medical records from one facility to another what is required?
To ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations, a signed release of information is required to release any medical records from one facility or provider to another.
What are health care advanced directives?
documents that communicate a person’s wishes about health-care decisions in the event the person becomes incapable of making health-care decisions.
What are the types of advanced directives?
living wills and health-care power of attorney
What is a living will?
A living will expresses a person’s preference for medical care.
