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Flashcards in Clin top test 1 Deck (77)
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1

What is standard of care?

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

2

Standard of care is determined by what?

Licensing board, peers and government.

3

What is a benchmark by which your performance is evaluated?

Standard of care.

4

What are primary records?

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

5

When should primary records be completed?

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

6

What are secondary records?

Clinical impressions, referral letters, treatment plans.

7

When should secondary records be completed?

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

8

What should secondary records not include?

Data that is not in the primary record.

9

What is ROF?

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.

10

What is a PARQ?

Procedure, alternative, Risk, and questions.

11

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

Clinic informatino provided to patient. Patient completes database information.

12

How is the paperwork for a history done?

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

13

What is done after the history?

Examination general physical and or regional physical exam.

14

What is done after the examination?

Ancillary studies like imaging.

15

What is done after the ancillary studies if any?

Chiropractic treatment plan.

16

What are the steps of the chiropractic treatment plan?

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.

17

What is after the chiropractic treatment plan?

Report of findings (ROF), PARQ

18

What is after ROF, PARQ?

Treatment (SOAAP notes).

19

What should be done after the Treatment?

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

20

What should be done after the re-evaluation?

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

21

How often should the patients name be on chart notes?

Every page.

22

How are changes/ deletions made to chart notes?

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

23

How is a diagnosis made up?

It is made up of pertinent positives and pertinent negatives.

24

What is a pertinent negative?

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

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.