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Terms Flashcards

1
Q

health record

A

written or graphic info. documenting facts and events during the rendering of patient care: either paper or electronic format

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2
Q

American Recovery and Reinvestment Act of 2009 (ARRA)

A

encourages implementation by offering five annual financial incentives for qualifying offices that convert to an electronic format beginning in 2011 and ending in 2015 or 2016.

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3
Q

Common Health record content

A
  1. Patient registration (demographic information)
  2. Medication record
  3. history and physical exam, notes or report
  4. Progress or chart notes
  5. Consultation reports
  6. imaging and x-ray reports
  7. Laboratory reports
  8. Immunization record
  9. Consent and authorization forms
  10. Operative report
  11. Pathology report.
    In hospital setting would also include
    - attending physician’s orders
    - date of admission
    - hospital stay dates
    - discharge date
    - discharge summary
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4
Q
  1. problem-oriented record (POR system)
  2. source-oriented record (SOR system or integrated system)
A

What types of systems are used in electronic health record system (EHR)

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5
Q

What types of systems are used in electronic health record system (EHR)

A

Consists of: flow sheets, charts, or graphs, that allow a physician to quickly locate information and compare evaluation

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6
Q

Soruce-Oriented Record System (SOR)

A

documents are arranged according to sections (e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR system filed in reverse chronological order. More difficult to locate data due to scattering throughout

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7
Q

Electronic Health Record System

A

collection of medical information about the past, present and future of a patient that resides in a centralized electronic system.

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8
Q

Difference between an EHR and an EMR

A

: An EMR is individual physician’s EMR for the patient, including medical history, allergies, and appointment information.
An EHR is all patient medical information from many information systems, including all components of the EMR.

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9
Q

Advantages of EMR

A
  1. no physical space required
  2. abstracting data is eliminated except when free-form documentation such as narrative notes, dictations, and natural language processing is used.
  3. free-text approach, encourages use of abbreviations or fewer spelled out words may result in scant or undecipherable documents.
  4. Electronic systems have built in security safeguards to protect against improper disclosure, unauthorized access, or unintended alteration of information for both the data and the system.
  5. ARRA requires covered entities to notify individuals if their protected health information is accessed or disclosed in an unauthorized manner.
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10
Q

SNOMED-CT

A

Systemized Nomenclature of Medicine for Clinical Terminology. Medical terminology cassification system that codes text data in an EHR system will assist in standardizing clinical medical terminology

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11
Q

Medicare Modernization Act

A

created the Commission on Systemic Interoperability to develop a strategy to make health care information abailable at all times to patients and physicians. Goal by 2014.

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12
Q

Electronic medical report

A

part of health record that is used to complete the insurance claim form.
permanent legal document that formally states outcomes of the patients’ examination or treatment in letter or report form.

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13
Q

Insurance claim

A
  • DOS, date of service
  • POS, place of service
  • Dx, diagnosis
  • Procedures
  • codes are used for interpretation by the insurance company when processing a claim
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14
Q

documenters

A

all individuals providing health care services that chronlogically record pertinent facts and observations about patient’s health.

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15
Q

documentation

A

charting, may be electronically handwritten, dictated and transcribed or downloaded from a (PDA) personal digital assistant or smartphone

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16
Q

Speech recognition system

A

computerized voice recognition system which makes it possible for computer to respond to spoken words

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17
Q

medical editor

A

correctionist, proofreads and edits the computer-generated documents

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18
Q

attending physician

A

refers to the hospital staff member who is legally responsible for the care and treatment given to a patient

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19
Q

consulting physician

A

provider whose opinion or advice regarding evaluatio or management of a specific problem is requested by another physician

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20
Q

non-physician practitioner (NPP)

A

nurse practitioner, clinical nurse specialist, licensed social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician assistnat who furnishes a consultation or treats a patient for a specific medical problem, pursuant to state law, and who use the results of a diagnostic test in the management of the patient’s specific medical problem

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21
Q

ordering physician

A

individiual in the hospital directing the selection, preparation, or administration of tests, medication, or treatment

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22
Q

primary care physician (PCP)

A

oversees the care of the patients in a managed health care plan and refers patients to see specialists for services as needed

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23
Q

referring physician

A

provider who sends the patient for tests or treatment

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24
Q

resident physician

A

physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center). Residents perform the elements required for an evaluation and management (E/M service in the presence of or, jointly with, the teaching physican, and residents document the service.

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25
Q

teaching physician

A

doctor who has responsibilities for training and supervising medical students, interns, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment. Teaching physicians must document that they supervised and were physically present at the time during key portions of the service provided to the patient when performed by a resident.

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26
Q

Treating or performing physician

A

provider who renders a service to a patient. In the Medicare program, the definition of a treating physician is a physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiary’s specific medical problem.

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27
Q

Five reasons for legible documention:

A

If handwritten, entries in patient record must be legible.
a. avoids denied or delayed payments by insurance carriers
b. enforcement of medical record-keeping rules by insurance carriers requiring accurate document that supports procedure and diagnostic codes.
c. Subpoena of health records by state investigators or the court for review.
d. Defense of a professional liabilty claim.
e. Execution of the physician’s written instructions by a patient care-giver.

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28
Q

E/M

A

Evaluation and management, occurs in office visit, inpatient hospital facilities, and nursing homes

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29
Q

CPT

A

Current Procedural Terminology

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30
Q

CMS

A

Centers for Medicare and Medicaid Services.

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31
Q

American Medical Association and Centers for Medicare and Medicaid Services.

A

Developed documentation guidelines for CPT E/M services.

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32
Q

Medicare administrator contractors

A

also called fiscal intermediaries, fiscal agents, and fiscal carriers, conduct reviews for irregular reporting patterns.
HAVE WALK IN RIGHTS, access to a medical practicde w/o apptment or search warrant.

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33
Q

Third-party payers and federal programs have responsiblity to ensure that professional services provided to patients were medically mecessary

A

Documentation must support the level of service and each procedure rendered.

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34
Q

medical necessity

A

criterion used by insurance companies, as well as federal programs, when making decisions to limit or deny payment. Payment may be delayed, downcoded or denied if the medical necessity of a treatment is questioned.

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35
Q

Good medical practice standards

A

Insurers differ on definition and may not cover services depending on the benefits of the plan.

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36
Q

ABN

A

Advance beneficiary Notice of Noncoverage, also know as waiver of liability agreement or responsibility statement

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37
Q

Audit

A

If provider has submitted insurance claims for payments deemed fraudulent or inappropriate by government.

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38
Q

External Audit Point System

A

A point system used while reviewing each patient’s health record during the performance of an audit. Points award only if documentation is present for elements required in health record. Point system is used to show where deficiencies occur in health record documentation, evaluation and substantiate proper use of diagnostic and procedural codes.

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39
Q

consequences of accidental (or intentional) miscoding.

A

HMO, PPO, private carriers can claim refunds
Medicare has power to levy fines and penalties and exclude providers from Medicare program

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40
Q

Insurance carrier and documentation

A

If it is not documented, then it was not performed. (have right to deny reinbursement)

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41
Q

Medicare carriers frequent audits

A

prepayment and postpayment audits to monitor accuracy physicians’ use of medical services and procedure codes.

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42
Q

Billing Patterns causing possible audits

A

a. billing intentionally for unnecessary services
b. billing incorrectly for services of physican extenders (NPP)
C. billing for diagnostic tests w/o separate report in health record
d. changing DOS on insurance claims to cmply with policy coverage dates
e. waiving copayments or deductibles, or allowing other illegal discounts
f. ordering excessive diagnostic tests
g. using 2 different provider numbers to bill the same services for same patient
h. failing to return overpayments made by the Medicare program
i. misusing prover ID number
j. using improper modifiers for financial gain

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43
Q

Common Medical Office Documents/
Documentation guidelines for Medical Services

A
  1. The health record should be accurate, complete (detailed), and legible.
  2. Documentation of each patient encounter includes or provide reference to following:
    a. chief complaint or reason for encounter
    b. relevant history
    c. physical examination
    d. findings
    e. prior diagnostic test results
    f. assessment, clinical impression, or diagnosis
    g. plan for care
    h. date and eligible identity of the health care professional
  3. The reason for encounter stated
  4. Past and present diagnoses
  5. Appropriate health risk factors should be identified
  6. The patient’s progress, response to and changes to treatment, planned follow-up care and instructions and diagnosis should be documented.
  7. Patient refusal to follow medical advise
  8. Procedure and diagnostic codes reported on the insurance claim form or billing statement supported by documentation.
  9. Confidentiality of health record maintained
  10. Each chart entry dated and signed
  11. Standardized charting procedures for progress notes. Use either SOAP or CHEDDAR styles or narriative or detailed descriptive style. Must be detailed enough to support current documentation requirements.
  12. Treatment plans written and consistent with working dx.
  13. medications prescribed and taken, listed
  14. request for or need for consultation must be documented. Include: consultant’s opinion, services ordered documented, and communicated to requesting physician.- see pg 96 for additional
    Four R’s: requesting, render, report, reason, (and possibly return”
  15. Record patient’s fialture to return for needed treatment, in Heath record, appointment book, financial reocrd or ledger, follow telephone call or letter to patient indicated
  16. How to correct documentation “errors”. see pg 96.
    Never delete or or key over incorrect data. or flag it as amended or obsolete and create an addendum typed as a separate document or for a chart note inserted below in the next space availabe. paper charting - initial correction. never erase, white, out or use self adhesive paper over any information record on a patient record.
  17. Document all lab tests, physcian intials report as read.
  18. Ask physician for approval for differnt code before transmitting claims
  19. Retain all records (until positive no longer necessary by conforming to federal and state laws, and physician wishes)
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44
Q

Contents of a Medical Report

A

Degree of documentation depends on the complexity of the service and the specialty of the physican.
history, examination, medical decision making

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45
Q

Documentation of History

A

includes:
chief complaint (CC), History of Present Illness (HPI), review of systems (ROS), past history, family, or social history (PFSID) extent of each depends on present problems

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46
Q

Chief complaint (CC)

A

concise statement usually in patient’s own words describing symptom, problem, condition, diagnosis, physician-recommended return, or other factor.
REQUIRED FOR ALL LEVELS OF HISTORY:

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47
Q

History of present illness (HPI)

A

chronological description of development of the patients present illness from first sign or symptom or from previous encounter to present (may include one or more of the following):
1. location,
2, Quality/Character of the symptom/pain,
3. severity or degree (1-10),
4. Duration,
5. Timing, when,
6. Context - situation associated with symptom
7. Modifying factors that make it better or worse,
8. Associated signs and symptoms

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48
Q

Review of Symptoms (ROS)

A

Inventory of body systems obtained through a series of questions that is used to identify signs or symptoms patient might be experiencing or has experienced. In ROS, trhe body systems are counted and totaled. The health record should describe one system of the ROS for a pertinent to problem level. For a complete level, at least 10 organ systems must be reviewed and documented.

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49
Q

Past History (PH)

A

Patients past experiences with illnesses, operations, injuries, and treatments

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50
Q

Family History (FH)

A

A review of medical events in the patient’s family including diseases that may be heriditary or place the patient at risk.

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51
Q

Social History (SH)

A

An age-appropriate review of past and current activities (smoking, alcohol, etc.)

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52
Q

Documentation review/audit worksheet

A

there are specific requirements of documentation.

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53
Q

Levels of history

A
  1. Problem focused (PF) chief complaint; brief history of present illness or problems
  2. Expanded problem focused (EPF) chief complain; brief HPI problem-pertinent system review
  3. Detailed (D) - Chief complaint; extended history of present illness; problem-pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, or social history direcdtly related to the patient’s problems
  4. Comprehensive (C) - chief complaint; extended HPI: ROS that is directly related to the problem identified in the history of the present illness, plus a review of all additional body systems; complete PFSH.
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54
Q

Physical Examination (PE or PX)

A

objective in nature consists of physcian’s findings by examination or test results

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55
Q

Physical exam Types

A
  1. Problem focused (PF)
  2. Expanded problem focused (EPF)
  3. Detailed (D)
  4. Comprehensive (C)
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56
Q

Problem focused (PF) physical exam

A

Problem focused (PF) physical exam

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57
Q

Expanded Problem focused (EPF) physical exam

A

A limited exam of affected body area or organ system and other symptomatic or related organ systems.

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58
Q

Detailed (D) physical exam

A

An extended examination of the affected body areas and other symptomatic or related organ systems.

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59
Q

Comprehensive (C ) physical exam

A

A general multisystem examination or complete examination of a single organ system.

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60
Q

Comorbidity

A

means underlying disease or other conditions present at the time of the visit.

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61
Q

Medical decision making (four types)

A
  1. straighforward (SF)
  2. low complexity (LC)
  3. moderate complexity (MC
  4. high complexity (HC)
62
Q

new patient (NP)

A

one who has not recieved any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years

63
Q

established patient

A

patient who has received professional services from the physican or another physician of the same specialty who belongs to the same group practice with the past 3 years

64
Q

consultation

A

includes services rendered by a physician whose opinion or advise is requested by another physican or agency in the evaluation or treatment of a patient’s illness or a suspected problem.

65
Q

referral

A

transfer of the total or specific care of a patient from physician to another for known problems. Not a consultation, ex. patient with fracture sent to orthopedist

66
Q

concurrent care

A

providing of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. (ex. cardiologist and endocrinologist)

67
Q

continuity of care

A

(e.g., a patient who has received treatment for a condition and is then referred by the physician to a second physician for treatment for the same condition),

68
Q

Critical care

A

intensive care provided in a variety of acute life-threatening conditions requiring constant “full attention” by a physician. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.

69
Q

Emergency care

A

it may be given by the physician in a hospital ED or in a physician’s office setting.

Emergency care is that is provided to acutely ill patients and may or may not involve organ system failure, but does require immediate medical attention.

70
Q

Emergency medical condition as defined by Medicare

A

medical condition that manifesting itself by acute symptoms of sufficient severity (including severe pain)

such that the absence of immediately medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part.

71
Q

Lay person definition of an emergency

A

Any medical condition of a recent onset and severity ,

including but not limited to severe pain, that would lead a produent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injry is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, seirous impairment to bodily functions, or serious dysfunction of bodily organ or part

72
Q

Counseling

A

discussion with a patient, family, or both concerning one or more of the following:

diagnostic results,
impressions,
or recommended diagnostic studies;
prognosis;
risks and benefits of treatment options;
instructions for treatment or follow-up;
importance of complication with chose treatment options;
risk factor reduction,
and patient and family eduction.

73
Q

imp (abbrevation

A

impression

74
Q

dx (abbreviation

A

diagnosis

75
Q

AMA policy on abbreviations

A

should be eliminated from vital sections of health record, such as final diagnosis, operative notes, discharge summaries, and descriptions of special procedures

76
Q

eponym.

A

term including the name of a person (e.lg. Graves’ disease)) s hould not be used when a comparable anatomic term can be used in its place
ex. “Buerger’s disease compared to thromboangitis obliterans

77
Q

acute

A

a condition that runs a short but relative severe course

78
Q

chronic

A

a condition that runs a short but relative severe course

79
Q

diagnostic terminology and abbreviations

A

problems can occur with documentation because of missing or misused essential words (ex. diastolic dysfunction instead of heart failure due to diastolic dysfunction

80
Q

within normal limits (WNL), noncontributroy, negative/normal, other than the above, all systems were normal

A

may not support billing of services, instead, documentation must indicate exatly which limb was examined and abbreviated wording would not pass an audit.

“CANNED” notes mean no assessment was actually performed, this is fraud.

81
Q

Detailed documentation justifies billed services by providing verification

A

ex. chest x-ray report reviewed, or read instead of “chest x-ray negative”

82
Q

surgical terminology

A

a) preoperative vs postoperative,
(b) simple/intermediate/complex
(c) undermining
(d) take down
(e) lysis of adhesion
(f) surgical position
(g) surgical approach (ex. vaginal vs. abdominal

83
Q

preoperative

A

(preop) period before a surgical procedure, begins with the first preparation to a patient fore surgery and ends with anestheia in operating room

84
Q

postoperative

A

(PO) period of time after surgery, beginning with patient emerging from anesthesia and continues through time required for acute effects of anestheia and surgical procedures to decrease

85
Q

surgical procedures for integumentary system

A

(example, repair of lacerations)

listed as simple, intermediate or complex repairs. Documentation should liste the length (in centimeters) of all incisions and layers of involved tissues so that correct procedure codes for excision of lesions and type of repair can be determined.

86
Q

simple laceration (superficial)

A

one layer closure

87
Q

intermediate laceration

A

requires layered closure of one or more of the deeper layers of the skin and tissues

88
Q

complex lacerations

A

require more than layered closure and may require reconstructive surgery

89
Q

If time is factor in coding for reimbursement.

A

Document length of time spent on procedure, especially if of unusual duration such as prolonged services, counseling, or team conferences. Stated somewhere in the report.

90
Q

State of art equipment

A

document

91
Q

Surgical procedures one of two categories

A

therapeutic or cosmetic procedures

92
Q

undermining

A

cut in a horizontal fashion

93
Q

take down

A

to take apart

94
Q

lysis of adhesions

A

destruction of scar tissue

95
Q

bilateral (term)

A

pertaining to both sides

96
Q

severe bleeding

A

blood lost of more than 600ml

97
Q

hermorrhage

A

escape of blood from vessels;bleeding

e.g. brain hermorrhage

98
Q

initial (key term/coding)

A

first procedure or service

99
Q

mulitple/parital (key term-coding)

A

affecting many parts of the body at the same time/only a part, not complete

100
Q

simple/subsequent

A

single and not compound or complex/second or more procedures or services

101
Q

unilateral (term)

A

pertaining to one side only

102
Q

internal reviews

A

prospectus review, prebilling audit or review done periodically (daily, weekly, monthly)

103
Q

Prospectus review, stage 1

A

review to verify that completed encounter forms match patients seen according to appointment book and have been posted on daysheet, then see if all charges are posted

104
Q

Prospectus review, stage 2

A

review verifies all procedures or services and diagoses listed on encounter form match data on the insuranc eclaim form.

105
Q

retrospective review

A

review done after billing insurance carrier, usually done by biller/coder to determine if sufficient documentation exists

106
Q

When diagnosis not completed correctly in health record:

A

an active dx has not been entered i nto the computer system and the computer defaults to the last dx given for established patient. OR dx is not linked to proceudre.
PROBLEMS MUST BE FOUND BEFORE BILLING AND CORRECTED BEFORE CLAIMS ARE PRINTED

107
Q

red flag in billing looking for billing excesses or potential abuse

A

unusual billing patterns
same dx code every visit
same procedure code repeatedly
lack of documentation
canned templates
illegible documentations
blank documentations
tests documented but not performed
same level of service consistently billed

108
Q

External audit

A

pg 114 & 115 discusses HIPAA credited to prevent fraud
discusses physician compliance programs

109
Q

compliance programs

A

composed of policies and procedures to accomplish uniformity, consistency and conformity in medical record keeping that fulfills official requirements.

110
Q

Compliance program elements or Elements of a Successful Compliance program

A
  1. written standards of conduct
  2. written policies and procedures
  3. compliance officer and/or committee to operate and monitor the program
  4. training program for all affected employees.
  5. process to give complaints anonymously
  6. internal audit performed routinely
  7. investigation and remediation plan for problems that develop
  8. response plan for improper or illegal activities
111
Q

software edit checks

A

audit prevent measure. Software program automatically screens transmitted insurance claims and electornically examins them for errors and/or conflict code entries.

112
Q

levels of service

A

insurance carriers expect to see different levels of service listed. If services are downcoded and physician neglected to document correct level of service, an addendum to medical record must be made to justify level of service reported. Amended chartge notes must be labeled “addendum” or “Late entry” dated on day of amendment and signed by physician.

113
Q

Fax transmissions for insurance claims

A

unless otherwise prohibited by state law, information that is transmitted by fax is acceptable, and may be filed iwth the patient’s health record.
1. fax is derived from facsimile
2. state law may prohibit transmitting claims information by fax
3. sensitive information should have a cover sheet
4. confirm the fax arrived at destination

114
Q

Sensitive information

A

from legal standpoint, protecting patient’s confidentiality in fax process crucial.

PATIENT MUST SIGN AUTHORIZATION TO RELEASE INFORMATION VIA FAX.

fax machines should be in secure, private location. a cover sheet always used containing recipient name, sender, date, total of pages, fax telephone numbers, a statement of personal, priviledged and confidential medical information intended for the named recipient only. with request that authorized receiver sign and return attached receipt form at bottom of cover letter. use coded reference number

115
Q

AHIMA (American Health Information Management Association) vs fax machine

A

do not use fax machines routinely
1. hand or mail delivery will not meet needs of immediate patient care
2. required by a third party for ongoing certification of payment for hospitalized patient

116
Q

what to not fax

A

American Health Information Management Association

117
Q

transmittal verification

A

verify fax was received or ensure fax received at destination or run log from fax machine

118
Q

Medicare fax policy

A

check with medicare fiscal intermediarey as to acceptability in faxing

119
Q

subpoena (term)

A

under penalty - writ requiring the appearance of a witness at a trial or other proceeding, see details on pp 118-120

120
Q

subpoena duces tecum (term)

A

requires witness to appear an dbring or send certain records in his possession

121
Q

PHI

A

protected health info.

122
Q

ESI

A

electronically stored info.

123
Q

ESI issues

A

concern that they may be altered, overwritten without leaving any evidence, or stored in several computer systems. Metadata or supportive data that is information on the computer system about the medical data

124
Q

Metadata

A

supportive data that is information on the computer system about the medical data such as
- substantive data is application based and may contain modifications, edits, or comments
- system-based data includes author, date and time when the entry was created, and date of modification
- embedded data is text, numbers, content direcdtly imput but not visible on output (eg., spreadsheet formulas or hyperlinks)

125
Q

notary subpoena

A

subpoena issued by notary public

126
Q

retention of records

A

preservation of health records governed by federal, state and local laws. see pp 120

127
Q

Federal False Claims Act

A

proof materials for the establishment of evidence should be kept indefinitely in event of legal inquiry. Calendars, appointment books and telephone logs also should be filed and stored.

128
Q

Federal Rules of Civil Procedure

A

makes requests for electronic data a standard part of the discovery process during federal lawsuits including health, accounting phone, instant messaging and electronic mail that might be needed for future litigation

129
Q

HIPAA (The Health Insurance Portability and Accountability Act of 1996) NPP (Notice of Privacy Practices) acknowledgements

A

kept for at least 6 years from date of creation

130
Q

Termination of a case

A

physican may terminate a contract
- sending a certified letter of withdrawal to patient (if refused by patient, file returned letter in patient’s chart)
- sending a certfieid letter of confirmation of discharge when patient states that he or she no longer desires care
- send letter confirming that the patient left the hospital against medical advise or the advise of physician, UNLESS signed statement in patient’s hospital records

131
Q

Reasons for proper medical record Documentation (four)

A

every patient seen by physician must have comprehensive legible documentation about what occurred during the visit for the following reasons; (1) avoidance of denied or delayed paments
2. enforcement of medical record keeping rules by insurance carriers
3. suppoena of health record by state investigators or the court for review
4. defense of a professional liability claim

132
Q

Electronic health record as tool

A

foremost tool of clinical care and communication

133
Q

Medical records evolving into electronic media

A

HIPAA directs adoption of national electronic standard

134
Q

CMS introduced documentation guidelines to Medicare carriers

A

ensures that services paid for have been provided and were medically necessary and that documentation must support the level of service and each procedure rendered

135
Q

External and internal audits

A

show where deficiencies occur in health record documentations and substantiantes proper use of diagnostic and procedure codes

136
Q

HIPAA medical records

A

must be signed or electronically verified by provider to show the note was reviewed and the test results were acknowledge

137
Q

Levels of E/M services are based on four types of physical examination:

A

problem focused, expanded problem focused, detailed, and comprensive

138
Q

retention of Records for living patients

A

Usual policy of physicans to retain medical records

139
Q

Error corrections for paper chart

A

Use a permanent ink pen to cross out an incorrect entry on patient’s record, mark though it with single line, and write the correct infoeramtion, then date an initial the entry.

140
Q

Error corrections for electronic medical record

A

note that a section is in error with date and time and enter the correct information with a notation of when and why the physician changed the entry.

Authenticate the correction via electronic signature and date. ALSO, could flag record as amended or obsolete and create an addendum either typed as a separate document or for a chart note inserted belowe in the next space availab.e

141
Q

Documenters

A

A. physician handwrites or dictates notes for patient visit
B. a transcriptionist or correctionist
c. receptionist/medical assistant
D. insurance billing specialist enters codes and/or claim information

142
Q

in situ (abbv term)

A

In the original or natural place or site.

143
Q

Physician charting methods

A
  1. SOAP
    subjective-objective-assessment-plan
  2. CHEDDAR
    chief complaint
    history of present illness
    examination
    details
    drug & dosage
    assessment
    return visit information or referral
144
Q

Function of the Medical Chart

A

Documents health information of patients
Resource for treatment planning
Mechanism of ____communication____ among health care providers
Serves as a __legal document_ _for a patient’s healthcare information
Since it is a legal document must careful in what you write in the chart

145
Q

Characteristics of Paper Chart

A

Storage: 3-ring binder
Hard cover protects paper
Sheets of paper can be easily manipulated
Can be used multiple times
Organization
Separated into logical sections by __tabbed______ dividers
Each tab is labeled with section heading

146
Q

Characteristics of Electronic Chart

A

Patient information is entered into a computer software program that is available throughout the hospital
Information separated into sections like a paper chart
Advantages over paper charts
Eliminates problems with _illegible___ writing
Easy to access data from previous admissions
Software may interface with labs, diagnostics, etc.
Software may offer physician order entry

147
Q

Using a Medical Chart: Flagging

A

Each facility has policies for medical chart use
Flagging
Process used to identify patient order status
Used to communicate what should be done next to ensure completion of patient orders
Types
Color-coordinated to communicate importance level of orders
Binder _positioning__ or placement

148
Q

Using a Medical Chart:Clipboards or Clip Charts

A

Extension of the medical chart
Contains daily information that is frequently updated or referenced
Frees up medical chart for use
Information filed in the medical chart at end of day
Used for day to day type of information blood pressure, glucose if diabetic, temperature, so you do not have to carry the entire chart.

149
Q

Typical Locations to Find a Medical Patient Chart

A

-Nursing Station
-Patient Bedside
-Rolling Chart Rack
-Outside Patient’s Room

150
Q
A

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