CLNAP Questions Flashcards
1
Q
If it wasn’t documented it wasn’t…………
A
Done
2
Q
What percent of medical diagnoses can be made based on the patient history alone?
A
80%
3
Q
What are the top 4 reasons for documentation?
A
- Communication with the healthcare team allows for continuity of care 2. Legal compliance ensures standard of care was provided, all recall is on the record, standardization 3. Reimbursement purposes (pts and provider) 4. Quality improvement and initiatives (data collection)
4
Q
What is the least important reason for clinical documentation?
A
Medical research
5
Q
Describe the clinician centered interview approach
A
- Used in the previous century 2. focuses on the disease process 3. Ignore patient feelings or factors 4. Limited relationship with patient and psychosocial sources 5. Parental approach
6
Q
Describe the patient centered interview approach
A
Emphasis on what is important to the patient (values) and their perceptions of illness
7
Q
What approach do we use to interview patients
A
Integrated approach (using both techniques)
8
Q
Give reasons for using the patient centered approach for interviewing patients
A
- Patients often seek healthcare for reasons other than a symptom 2. Hearing the full story from the pt is important diagnostically and therapeutically 3. Helps sort out the needs of patients who bring more than one concern 4. Gives a voice to our care and compassion as clinicians 5. Quality improvement
9
Q
What competencies are important for the physician in using the patient centered approach to interviewing
A
Genuineness Respect empathy Professionalism Time management
10
Q
What is the average time it takes for a physician to interrupt the patient while telling their story?
A
18 seconds
11
Q
What model should we use for empathy?
A
N ame U nderstand R espect S upport
12
Q
What steps are involved in setting the agenda for the patient?
A
- Elicit the chief concern 2. Indicate the time available 3. Review with the patient what you foresee discussing 4. Summarize the final agenda
13
Q
How long should physicians give the patient to speak about their chief complaint?
A
2 minutes
14
Q
List some potential communication barriers while interviewing the patient
A
- HOH - Poor lighting - Cognitive disturbances - Patient distrust - Noisy setting - Visual impairments - Language barriers - Technology
15
Q
What are the four types of questions we’ve discussed and indicate when it is appropriate to use them
A
Open ended: eliciting the CC Closed ended: ROS Focused: getting more information about the CC Leading: NEVER!
16
Q
How many components of LOCATES are required to bill at the highest level?
A
4
17
Q
What does LOCATES stand for?
A
Location, Other sxs, Sharacter, Aggravating/Alleviating, Timing, Environmental factors, Severity
18
Q
What should you always do after your collected the HPI and move into the PMH?
A
SUMMARIZE
19
Q
Explain sensitivity
A
Probability of a positive test given you have the disease - Good at ruling out - Few false negatives - ex: photophobia is a sensitive for migraines (fairly predictive of migraines)
20
Q
Explain specificity
A
Probability of a negative test given you do not have the disease - Good at ruling in - Few false positives - Ex: chest pain for less than 1 minute is less likely to be a heart attack (specific indicator)
21
Q
If a strep test is 99% specific, out of 100 patients who don’t have strep, how many will have a negative test?
A
99 (few false positives)
22
Q
If a strep test is 80% sensitive, out of 100 pts with strep how many will have a positive test?
A
80, 20 will have a false negative test
23
Q
What is the proper order for the complete H&P?
A
Date Time CC HPI PMH SH FH ROS PE A P Sign - PA-S1
24
Q
If a patient says they are dizzy, what should you distinguish this from?
A
Light headedness
25
True or false: it is not appropriate to interpret data while collecting it in the HPI
True
26
What is CMS and what did they develop?
Centers for Medicare/Medicaid Services developed E/M (Evaluation/Management) coding to standardize levels of service
27
What are CPT codes?
procedure codes based on the level of service. Can be based on new or established patients and the time spent reviewing the chart or counseling
28
What are ICD-9 codes?
explain the reason for service (17,000 possible codes)
29
What is the newest version of ICD-9? When will it be released? How many codes are possible?
ICD-10, October 2013, 155,000 codes
30
What should never be used as a dx?
"rule out..." use suspected instead
31
True or false: coding for URI and coding for cough in the same pat for the same exam is acceptable
False: no double coding
32
True or false: it is not important to code for chronic illnesses if they contribute to the CC
False: you can code for them as long as they are pertinent to the CC
33
What is the purpose of EMR?
- Process data - reminder tools - descision making tools - preventative health charts - drug interaction systems - easier E/M coding
34
A good EMR should be able to perform...
- Health information data - Results and order management - decision support - e-communication and connectivity - patient support - Reporting - Administrative processes
35
What are the benefits of EMR?
- immediate access to key information - quick access to new and old information - legibility - reduced duplication and fragmentation - regular screenings - continuity - epidemiologic surveillance - quality management
36
What are downfalls of EMR?
- Computer literacy - Cost of implementation - Confidentiality - Technical issues - Systems adaptable to diverse environments (ED, OPD) - Lack of interoperability (different systems communicating with each other)
37
What mnemonic is used to gather PMH?
A adult illness/allergies H Hospitalizations I Immunizations S Surgeries T Trauma O Oral medications R Reproductive Y Youth illnesses
38
A remote hospital stay means what?
it was years in the past
39
What should be included when inquiring about immunizations?
What, When, up to date? Reactions?
40
What immunizations cannot be given to immunocompromised pts?
MMR Varicella Live flu
41
The influenza vaccine is contraindicated in pts with this allergy
Egg
42
What should be included when inquiring about surgeries?
Reason, what it was, when it occurred, complications, residual debilities
43
What "rights of medications" should be indicated under oral medications?
Drug Dose Root of administration Frequency Duration Side effects Allergies
44
What should be included when inquiring about reproductive history?
- LMP - Menopause and year - Gravida (time pregnant)/ Parity (viable births) - First menses - Contraceptives - IPV - STD - Fertility - Intimate partner violence
45
What question is asked to screen for intimate partner violence?
Do you feel safe in your home?
46
What types of youth illnesses should be documented in the PMH?
Chronic, major conditions with long term sequela - Ex: rheumatic fever, leukemia, measles
47
When should you include spouse information int he FH?
fertility issues and genetic counseling
48
When mnemonic is used to collect SH?
F Family/food/faith L living arrangements A activity M marital status E education/economic/exposures (pets, travel) S screenings/sexual history/substance abuse/safety
49
What are the "P"s of sexual history?
Partners Practices Protection Prevention of pregnancy Past STD
50
How many systems are identified by CMS guidelines?
14
51
How many systems are required for the highest level of billing?
12
52
What are the 14 systems identified by CMS?
Constitutional Eyes ENT CV Respiratory GI GU MSK Neurologic Psychiatric Endocrine Hematologic/lymph Allergic/immunologic Integumentary
53
What setting usually uses MDM in their documentation?
ED
54
What fraction of ambulatory care are well visits?
1/5
55
What is considered primary prevention?
complete prevention of illness: vaccines, hand washing, safer sex
56
What is considered secondary prevention?
Aim to detect disease in earliest asymptomatic stages: mammography, HIV screening, PSA testing
57
What is considered tertiary prevention?
Aim at eliminating consequences of disease: most health care measures (DM II)
58
Define health maintenance
holistic approach to minimize illness and death
59
Define screening
Any test used to detect disease in those at risk
60
Identify common modifiable risk factors
exercise diet/nutrition BMI tobacco use EtOH/Drug use Sexual practices Partner violence Safety measures occupational history oral health blood product transfusions
61
What is the recommended exercise for healthy adults?
30min/day X 5 days weekly combined cardio and weight training
62
What other related conditions should be screened for when discussing exercise?
Anorexia, over-exertional syndromes (dehydration, osteoporosis)
63
What BMI is considered over weight? Which is considered obese?
Overweight: \> 24.9 Obese: \> 30
64
For a 1,800 calorie per day what percent should come from carb, protein and lipids?
50% carb 30% protein 20% lipid
65
How is BMI calculated?
(weight in lbs /height in inches(squared)) X 703
66
What fraction of Americans still smoke?
1/5
67
What percent of all deaths is directly or indirectly related to smoking?
20%
68
What has shown to improve outcomes of smokers quitting?
2 minutes of education about health benefits, support systems, meds, or psychodynamic factors
69
What is the number of pack-years for a pt who smoked 1 ppd/40 years?
40 pack-years
70
What is the number of pack-years for a pt who smoked 2 ppd/40 years?
80 pack-years
71
What mnemonic is used for alcohol abuse?
C cut down A annoyed G guilty E eye opener Those with 2+ responses have a 7 fold risk of dependence above the general population 75% sensitivity
72
What questionnaire was developed by WHO for alcohol abuse?
AUDIT 94% sensitive
73
What surveys are used to determine drug abuse?
DAST-10 NIDA modified assist
74
Explain DAST-10
10 item self report yes/no intended for \>18
75
What is the female prevalence for intimate partner violence?
50% in a lifetime
76
What type of women are at higher risk for intimate partner violence?
Pregnant women Those with FH
77
When do children need a carseat?
4 years old or 40 lbs
78
What group of people are at higher risk for developing oral cancer?
\>55 in smokers/drinkers or those with HPV
79
What is gum disease linked to?
Increased risk for CVD
80
What complications can occur from blood transfusions?
anaphylaxis iron overload TRALI Hemolytic reactions
81
What are red flags in the FH that indicate hereditary risks?
- early age of onset - two or more 1st degree relatives - two or more conditions in one relative - conditions that are refractory to prevention and treatment
82
When is a colonoscopy indicated?
\> 50
83
When is FOBT indicated?
\> 40
84
When is mammogram indicated?
\> 40 and annually
85
When is a PAP indicated?
after 21 or sexual activity and 3 years after 2 normal results
86
When is a DEXA indicated?
\> 65
87
When is HIV and Syphillis indicated?
\> 18 and at risk
88
When is a breast exam indicated?
\> 20 and every 3 years to 40 then yearly
89
When is PSA and prostate exam recommended?
\> 40 and yearly
90
When is hernia and testicular exam indicated?
18 and yearly
91
What are the components of the WWE
GYN history Bimanual pelvic and PAP Clinical breast exam Mommogram if indicated Others as per USPSTF
92
What are the components of the WME
Testicular, hernia, prostate, rectal, FOBT, PSA, sexual health exams
93
What does a deferral of treatment imply?
It will be taken care of at a later date
94
What age is baseline determined for geriatric pts?
65
95
What index evaluates ADL?
Katz index bathing, dressing, continence, transferring, feeding
96
What index evaluates IADLs?
Lawton index Shopping, driving, phone, cooking, housekeeping, laundry, finances
97
When should you screen for glaucoma?
\>60 or earlier with risk
98
What is involved in the mini cognitive test?
3 item recall and clock drawing
99
What assesses the mood and depression of geriatric pts?
GDS (geriatric depression scale)
100
What evaluates the nutrition of geriatric pts?
MUST testing looks at wt loss, BMI, illness effect
101
Pediatrics encompass until what age?
21 y/o
102
What is the EPSDT program?
Medicaid mandate - growth (BMI, head, length, weight) - developmental (language, Denver developmental screening test) - Lab - Immunization - Anticipatory guidance - Risk factor ID
103
When is lead screening performed?
1 and 2 years of age
104
What labs are acquired on neonates?
PKU congenital hypothyroidism SSA Neonatal hyperbilirubinemia
105
What topics should be discussed with neonate parents?
breastfeeding, sleep positioning
106
What topics should be discussed with parents of 4 month olds?
teething, injury prevention
107
What topics should be discussed with parents of 1 y/o?
baby proofing, dental hygiene
108
What topics should be discussed with parents of 2 y/o?
decreased appetite, toilet training
109
What topics should be discussed with 10-14 y/o?
safe sex, safety issues, peer issues, drugs
110
When should a maternal history be documented for peds?
\< 2 y/o - include pregnancy loss, medications, drugs, etoh, environmental risks, infections (TORCHs)
111
What is HEEADSSS and when is it used?
Assessing pediatric pts H home E education/employment E eating A activities D drugs S sexuality S suicide/depression S safety
112
What is the most common form of child abuse?
neglect
113
What are typical coping mechanisms after learning bad news?
Denial Acting out Identification Intellectualization Reaction formation Regression Sublimation
114
Explain identification
patterning behavior after someone else
115
Explain intellectualization
explaining away the unreasonable in form of logic
116
Explain reaction formation
setting aside unconscious feelings and express that exact opposite
117
Explain regression
Resorting to child-like behavior
118
Explain sublimation
Taking instinctual drives and funneling that energy into a socially acceptable action
119
What are the stages of behavioral change? "Transtheoretical model"
Precontemplation Contemplation Preparation Action Maintenance
120
What is the precontemplation stage?
Pt lacks appropriate awareness
121
What stage of behavioral change requires the most help from the physician?
Preparation
122
How should you end the interview?
Educate the pt using the teach back model Obtain a commitment Set goals Negotiate
123
How should you approach the reticent patient?
Be candid about what you want to know Use emotion seeking skills Use focused, closed ended questions
124
How should you approach the overly talkative patient?
Redirect them
125
True or false: exams including interpreters are generally 3x as long as a normal visit
False: 2x
126
Describe the pt with dependent personality
Fear abandonment Require much attention and care - Give more guidance and advice, f/u frequently - physician can become frustrated and reject the pt
127
Describe the pt with obsessive compulsive style
Preoccupation with detail, isolate themselves from emotional intimacy - involve the pt, give lots of detail, compliment their detail - Battle for control with the physician
128
Describe the pt with histrionic style
Requires attention of everyone, sexually and emotionally, seductive - respond with frequent compliments, respond calmly and firmly, reassurance - Physician distances themselves
129
Describe the pt with self defeating style
Repeated failure, victimization - Give empathy, avoid reassurance, use a less upbeat style
130
Describe the pt with narcissistic style
Overly entitled, smug, arrogant - make pt feel they are unique, don't downplay their ego, engage on a medical level
131
Describe the pt with paranoid style
Negative interpretation of other people's work, actions, and intent, guarded, no delusional or perceptual disturbances - Provide full information, avoid becoming too close, do not reinforce or dispute their feelings
132
Describe the pt with schizoid style
Socially withdrawn, introverted, no perceptual disturbances, illness triggers denial - avoid becoming too close
133
Describe the pt with borderline personality disorder
Wildly emotional splitting self-destructive dissociate with negative experiences
134
Describe the pt with avoidant personality disorder
extreme inadequacy avoids new things
135
Describe the pt with antisocial disorder
law breakers violates rights of others seductive
136
Describe the pt with schizotypical disorder
Magical thinking carvoyant isolated socially closest to schizophrenia in cluster A disorders
137
What are the cluster A disorders?
The weird -paranoid, schizoid, schizotypical
138
What are the cluster B disorders?
The aggressive (histrionic borderline, antisocial, narcissistic)
139
What should be included in MDM in regards to patient personality?
- difficulty or barrier to interaction - avoid making diagnoses of personality disorders - patient understanding and commitment
140
What mnemonic is used to assess depression?
S sleep I interest G guilt/worthlessness E energy C concentration/cognition A appetite P psychomotor (agitation, slowing) S suicide
141
What mnemonic is used to assess dementia?
D diabetes/dementia/drugs E epilepsy M migraine/multiple infarction dementia E ethanol (withdrawal/toxicity) N neurological deficit disease (BETA)/ nutritional deficiency) T TIA/trauma I insulin/infections A Alzheimer's disease/abscess
142
What mnemonic is used to assess neurological deficit disease?
B bleeds E encephalitis T tumors A abscess/meningitis
143
What is the HbA1C used for?
evaluating 3 month BS levels \>6% = BAD
144
What information regarding the pt is included in demographic and billing?
Name DOB Address/phone Guardian Insurane Maital status Employer Avoid SSN
145
What should the initial consult note include?
- comprehensive H&P - assessment - recommendations (care, management, additional work-up) - periodic updates to PCP - Letter of request with clinical information - Letter sent back from consultant
146
What does the living will express?
preferences in care - cardiopulmonary resuscitation, ventilation, artificial nutrition, hydration, DNR orders TRUMPS DPOA
147
What is a DPOA?
Durabl power of attorney - patient named proxy to make decisions - covers a broader range of situations
148
What is a DNR-cc?
Work to save the pt until you need to take extraordinary measures
149
What is a DNR-arrest?
Work to save the pt until there is no pulse
150
True or false: only document a phone call to a pt if they answer and speak to you
False: any attempts should be documented
151
When presenting the PE what should be given first?
vitals
152
When should shorter synopses of pts be given?
ED Focused complaints
153
When should BP be checked in adults?
at 18 y/o and every 2 years after
154
When should cholesterol levels be checked in adults?
Men: 35 - 65 y/o Women: 45 - 65 y/o
155
When should Baby aspirin be considered to prevent heart attack in adults?
Men: 40 y/o Women: 50 y/o
156
When should men be checked for abdominal aortic aneurysm?
Between 65-75 y/o if they have ever smoked
157
When should women be checked for breast cancer?
40 y/o and every 1 to 2 years
158
When should women be checked for cervical cancer?
21 y/o and 3 normal in a row then every 3 years after that
159
When should adults be checked for colorectal cancer?
50 y/o yearly
160
When should women be checked for chlamydia or gonorrhea?
18-25 y/o and then men and women at risk after that HIV and syphilis is only for those at risk)
161
When should women be checked for osteoporosis
65 y/o and yearly
162
When should adults be immunized for the flu?
65 y/o and annually
163
When should adults be immunized for pneumonia?
65 y/o once
164
What further testing does a positive FOBT call for?
colonoscopy
165
How often should a colonoscopy be performed?
every 10 years
166
When should a digital rectal exam be performed?
40 y/o and at the time of a flexible sigmoidoscopy or colonoscopy
167
When should a flexible sigmoidoscopy be performed?
50 y/o with a negative FOBT
168
What are the cluster C personality disorders
The nervous (avoidant, obsessive compulsive disorder, dependent)
