Clinical Documentation Flashcards
found in medical record chart along with (administrative documentation)
Clinical Documentations
Clinical Documentations includes services and procedures which are the ff :
— Patient encounter
— Pathology & laboratory testing
— Diagnostic studies
— EKGs
Clinical Documentations various formats & types of reports :
— History & Physical (H&P)
— Progress notes
— Consultation report
— Orders
— Operative reports
— Radiology / Nuclear Medicine Reports
— Discharge Summary
What is a History & Physical (H&P)?
information pertaining to the patient’s health history and current condition
What are progress notes?
documentation of a patient encounter
What is a consultation report?
includes physical examination, test results, and along with the consultant’s expert opinion about the PT’s condition
What is an order(s)?
a request made by the provider to receive services, labs, diagnostic tests, therapies, or medication (without an order these services cannot be performed); this includes dx statement to why the order is needed
What are Operative reports?
surgeon dictated report containing details about the procedure performed (why was it necessary, operative findings, and the condition of the pt at the end of the procedure
What are Radiology / Nuclear Medicine Reports?
a report written by the radiologist which describes the findings and assessment of radiology films or nuclear medicine tests
What is a Discharge Summary?
summary of an inpatient or surgical encounter including :
— Last face-to-face encounter
— Physical exam
— Review of medications
—Discharge orders for home health or physical therapy
— Any other instructions for the pt
What is clinical concepts?
essential to medical codes used for billing and reporting
What are some examples of clinical concepts?
— Anatomy
— Complicated by
— Episode
— History of
— Severity
— Symptoms
What are code assignments often made by?
by using the search feature only the relevant key terms were used
What are the standard code sets and what are they used for?
terminology standards & SNOMED-CT — used for clinical documentation
CPT, ICD-10, HCPCS — used for billing
What are examples of terminology standards and what are they for?
— Logical Observation Identifiers Names and Codes (LOINC) - for laboratory tests, measurements, and observations
— National Drug Code (NDC) – for drugs
— Centers for Disease Control (CDC) and Prevention – vaccines administered
— use of abbreviations & acronyms
maintains a list that is not recommended for use, because of the potential causing medical errors
Joint Commission
— classify medical treatments, tests, procedures, supplies & equipment, and diagnoses identified in medical records
— used in EHR transactions for billing and for research & population health management
— regulated by HIPAA Administrative Simplification
Code Sets
ICD-10
includes both ICD-10-CM for diagnosis codes and ICD-10-PCS for inpatient procedure codes
CPT
outpatient services/procedures
HCPCS
services not included in CPT
CDT
dental procedures
NDC
drug products
This is the medical code sets US primarily uses for reporting & billing purposes…
HCPCS (Level I codes and Level II National Codes) and ICD-10-CM and ICD-10-PCS
It has direct correlation to these primary code sets because they have assigned values…
Revenue Cycle
