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Clin Topics Q6 > Clin top test 1 > Flashcards

Clin top test 1 Flashcards

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1
Q

What is standard of care?

A

The expected diligence and care that a provider would use in assessing and managing a patient.

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2
Q

Standard of care is determined by what?

A

Licensing board, peers and government.

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3
Q

What is a benchmark by which your performance is evaluated?

A

Standard of care.

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4
Q

What are primary records?

A

Those obtained with the patient present - history, physical examination, ancillary studies.

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5
Q

When should primary records be completed?

A

At Contemporaneous (living or occurring during the same period of time).

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6
Q

What are secondary records?

A

Clinical impressions, referral letters, treatment plans.

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7
Q

When should secondary records be completed?

A

The doctor completes later and which indicate the doctor’s clinical thinking and plans.

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8
Q

What should secondary records not include?

A

Data that is not in the primary record.

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9
Q

What is ROF?

A

Report of findings- an explanation by doctor to patient, in language and concepts the patient can understand, of the diagnosis, plan of management and prognosis.

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10
Q

What is a PARQ?

A

Procedure, alternative, Risk, and questions.

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11
Q

What is the first paperwork done/ given to a new patient?

A

Clinic informatino provided to patient. Patient completes database information.

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12
Q

How is the paperwork for a history done?

A
  1. Chief complaint. 2. Review of systems. 3. Past health history. 4. Family health history. 5. Personal and social health history.
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13
Q

What is done after the history?

A

Examination general physical and or regional physical exam.

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14
Q

What is done after the examination?

A

Ancillary studies like imaging.

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15
Q

What is done after the ancillary studies if any?

A

Chiropractic treatment plan.

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16
Q

What are the steps of the chiropractic treatment plan?

A
  1. Problem list/ diagnoses. 2. Goals and outcome markers. 3. Treatment (in office and home care). 4. Initial clinical impression- explain diagnosis. 5. Prognosis- explain. 6. Medications list.
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17
Q

What is after the chiropractic treatment plan?

A

Report of findings (ROF), PARQ

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18
Q

What is after ROF, PARQ?

A

Treatment (SOAAP notes).

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19
Q

What should be done after the Treatment?

A

Re-evaluation: interview and exam (reconsider DDx, ancillary studies, treatment plan, etc.).

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20
Q

What should be done after the re-evaluation?

A

New chiropractic treatment plan; re-evaluate type of clinical impressions.

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21
Q

How often should the patients name be on chart notes?

A

Every page.

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22
Q

How are changes/ deletions made to chart notes?

A

Draw a single line thorugh the incorrect item and date and initial this.

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23
Q

How is a diagnosis made up?

A

It is made up of pertinent positives and pertinent negatives.

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24
Q

What is a pertinent negative?

A

When someone answers no to an answer, and it is relevant.

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25
What is HIPAA?
Health insurance portability and accountability act.
26
The security rule of HIPAA is limited to who?
Electronic PHI this inculdes anyo health care or provider or anyone in the industry who uses electronic means for transmission including electronic billing, faxes, and email.
27
What is portability?
Being able to take health insurance benefits with you when you leave the job (COBRA).
28
What is accountability?
Making sure the patients PHI is kept confidential.
29
What parts of a patients privacy will HIPPA protect?
visual and auditory privacy, and prevents unauthorized access.
30
How can a buisness comply with HIPPA?
Train staff, physical security measures, have confidentiality agreements with all business associates.
31
What is a problem list?
List that includes any significant complaint or finding that may affect the patient's health, treatment, or expected outcome.
32
What are the 6 categories that are included into the problem list?
1. Problems being treated (they have been diagnosed). 2. Problems waiting to be diagnosed. 3. Problems that are being monitered. 4. Problems being managed elsewhere. 5. Patient issues that will not change. 6. Identified risk factors for the patients health.
33
What is required before a treatment can be done?
A diagnosis.
34
Review of systems ROS is aka?
Other current problems.
35
ROS must include what?
Asking questions about the major organ systems.
36
What should be done with pertinent info on a ROS sheet?
make sure that you follow-up on any box that has been checked by the patient and put a small notation with the pertinent follow-up information on the yellow form.
37
What parts of family health history must be included in the history?
All items in the chief complaint history must be asked and the rest can be truncated if time is not available.
38
What are the goals of taking a past health, family and lifestyle history?
Identify other diseases or problems affecting the patient, identify risk factors, identify any info that may be connected to the chief complaint, learn about things that may affect treatment and management issues.
39
What questions should be asked after a positive response to a past health history question?
What, when, outcome/ residual effects.
40
NRE equals what?
No residual effects.
41
HRT means what?
Hormone replacement therapy.
42
What is the difference between effects of last treatment vs. pre-treatment assessment?
Pre-treatment assessment is your undrestanding of how the patient is today compared to how the patient was on the last day they were seen. Effects of last treatment is not the same as how they feel today.
43
What is the difference between subjective and objective?
Subjective- stuff only the patinet can know, and must tell the doctor. Objective- stuff only the doctor can check.
44
When should a new complaint or aggravation be re-evaluated?
If there was significant trauma or the doctor must revisit the main clues from the original problem to determine whether this is a new problem or simply an aggravation.
45
What is the tenderness grading scale like?
Positive 1/4- Tenderness with no physical response, +2/4- tenderness with grimace and or flinch, +3/4- Tenderness with withdrawal, +4/4- tenderness to non-noxious stimuli.
46
What is activity modification?
Avoding, curtailing or changing when or how common activities of daily living are done.
47
What should the supervising clinician do with all time sensitive referrals?
Follow up on them within 24 hours.
48
What should be done with all semi-urgent and immdediate referral cases?
A referral letter should be sent with the patient.
49
What should be done after follow ups and contacts have been made after a referral?
This should be recorded in the chart notes.
50
What should be done if a patient does not have anything to be added to an area of chart notes?
Never leave a blank write NA or NP-not performed.
51
What would a check and a circle mean on chart notes?
Check means that the test was performed and the findings were normal. Circle- means that a test was performed and the results were abnormal.
52
What is an ancillary study?
Any additional specialized diagnostic evaluation beyond history and physical examination.
53
What is the code system used in the clinic?
ICD-9-CM
54
What does ICD-9-CM stand for?
international classification of diseases clinical modification and this is the 9th edition.
55
When will electronic billing be mandatory?
Janurary 1, 2012.
56
What are the 4 parts to writing a diagnosis?
1. Pathoanatomical component or named syndromes. 2. Neurological or radiating component. 3. Biomechanical or soft tissue component. 4. Local structural complications.
57
Since joint restriction is a physical exam finding that can support a diagnosis what should the diagnosis be?
Joint dysfunction or subluxation syndrome.
58
Every problem that is being treated must have what that can act as outcome markers?
Treatment goals.
59
What is the general rule for charting?
If its worth doing, its worth charting. This will include all tests done even if the test come up negative.
60
How will the DTR scale work?
1+ - present but depressed. 2+ - normal/average. 3+ - increased. 4+ - clonus.
61
How will the muscle testing scale work?
5- normal. 4- complete ROM against gravity with some resistance. 3- complete ROM against gravity but with no resistance. 2- Poor or complete ROM with gravity eliminated. 1- trace or evidence of slight contractility, no joint motion. 0- no evidence of contractility.
62
Who should make the short term/ intermediate goals and who should make the final goals of therapy for outcome measures?
Short term- Practitioner. Final- critical that patient is involved, but practitioner also.
63
What are the 3 Groups of outcome measures?
1. Symptom relief. 2. improve specific activity intolerance or improve ADL-related function. 3. Improve physiological/ biochemechanical function.
64
What is a prognosis?
Your expert opinion at this specific time based on what you know about the patient and the condition.
65
What things should be included in a prognosis?
1. Problem list number. 2. qualitative statement regarding how the patient will do. 3. What end point is expected/ hoped for. 4. Give your reasons for your choices for #2 and 3. 5. Clearly state any significant residual effects or likelihood of recurrence. 6. Time and or number of visits needed to reach anticipated end point.
66
What is the initial part of a Chiropractic treatment plan CTP?
a new short desription of the patients diagnoses along with the key findings that support the diagnoses.
67
What is the re-evaluation part of a CTP?
a brief description of the impact that time and teatment have had on the pateints condition along with key findings which documented changes in the patients condition.
68
What should be done once a diagnosis has been made?
Report of findings (ROF) and this should be charted in the SOAAP notes.
69
What should be done after a ROF?
PARQ.
70
How is pre-treatment assessment done?
compare your subjective and objective findings with the last SOAAP notes.
71
What are the 3 parameters of pain?
1. intensity. 2. Duration. 3. Area.
72
What will medicare and many other insurance companies require to be used for documentation of need for treatment?
2 out of the 4 components to PART and must have A or R.
73
At UWS hoe will you indicate what treatment you intend to perform on the route slip?
Circle the appropriate CPT code and your clinician gives you permission to treat by initailing the approved CPT codes and siging the bottom.
74
What is the first step in doing a re-evaluation?
review the problem list.
75
What are the 3 types of outcome markers we want to use for each problem?
1. subjective information. 2. ADL's and activities. 3. Physiological/biomechanical findings (objective).
76
What is palliative care?
treatment/ care delivered to relieve the symptoms associated with an injury or illness but ersult in no net improvement in the pateints underlying condition and are delivered during periods of symptomatic aggravation as requested by the patient.
77
What is supportive/maintenance care?
treatment delivered to prevent or reduce the reoccurrence of illness and or impariment.

Clin Topics Q6 (1 decks)

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