Basic Medical Documentation

Question 1

What are some roles of medical assistants?

Answer 1

• documentation: recording information in the medical record
• maintenance: verifying accuracy
• releasing: with proper signatures and verification

Question 2

What is the purpose of medicla records?

Answer 2

• support patient claims of malpractice against a doctor
• support the doctor in defense against a claim
• back up the information within the financial record

Question 3

What is a noncompliant patient?

Answer 3

medical term used to describe a patient who does not follow the medical advice they receive

Question 4

What is the content of the patient medical history?

Answer 4

• past illnesses, surgeries
• family medical history
  social history (food, drinks, drugs)
• history of present illness

Question 5

What contents are found on a patient’s medical record?

Answer 5

• laboratory results and tests
• release of records
• operative reports, hospital discharge forms
• telephone calls
• specialist evaluations
• consent forms

Question 6

What is included in a physical examination form?

Answer 6

• review of systems: identifies any signs or symptoms the patient may be experiencing that may reveal information about an illness
• doctor’s diagnosis and treatment plan

Question 7

What are the patient rights regarding their PHI?

Answer 7

• right to notice of privacy practices
• right to limit or request restriction on their PHI and its use and disclosure
• right to confidential communications
• right to inspect and obtain a copy of their PHI
• right to request an amendment to their PHI
• right to know if their PHI has been disclosed and why

Question 8

What is PHI?

Answer 8

protected health information

Question 9

What is SOMR?

Answer 9

source-oriented medical records

Question 10

How should SOMR information be grouped?

Answer 10

• progress notes
• laboratory
• radiology
• correspondence

Question 11

What order should forms and progress notes be filed in?

Answer 11

reverse chronologic order
- newest on top

Question 12

What is SOAP documentation?

Answer 12

S - subjective: chief complaint
O - objective: measurable data, vital signs, lab results, measurements
A - assessment: medical diagnosis
P - plan: treatment

Question 13

What is the CHEDDAR format?

Answer 13

C - chief complaint, presenting problems, subjective statements
H - history, both social and physical
E - examination, including extent of body systems examined
D - documented details
D - drugs and dosage
A - assessment of diagnostic process and diagnosis
R - return visit information or referral

Question 14

What color ink should we use for notes?

Answer 14

black or blue
- highlight specific items like allergies

Question 15

How do you mark out mistakes?

Answer 15

single strike through line then insert correct information
- include date, add time, and initial correction

Question 16

What is a release of information form?

Answer 16

• indication of who will receive the records and a reason

Question 17

What is the legal and ethical principle?

Answer 17

protects the patient’s right to privacy at all times

Question 18

Who is considered an adult?

Answer 18

• 18 years old
• emancipated minor
• mature minor (STI, birth control, drug or alcohol counseling)

Question 19

What is an audit?

Answer 19

to examine and review a group of patient records for completeness and accuracy

Question 20

Why are audits done?

Answer 20

• determine their ability to back up the charges sent to health insurance carriers
• verify that the medical documentation meets required minimum standards

Question 21

What are the 2 types of audits and their features?

Answer 21

1) internal audits:
- review of their ability to back up the charges sent to health insurance carriers
- look for “failure to document”
- meet the required standards
2) External audits:
- performed by government entities, managed care organizations, and private insurance carriers
- to see if medical record documentation backs up billing

Question 22

What must be established in a patient interview?

Answer 22

• a relationship
• information exchange
• reason for appointment
• chief complaint

Question 23

What nonverbal clues should we pay attention to?

Answer 23

• facial expressions
• gestures
• tone of voice
• body language
• appearance

Question 24

What are the main steps to interview a patient successfully?

Answer 24

• do research (review medical record)
• request the interview (consent)
• make the patient feel comfortable
• ensure privacy/no interruptions
• be respectful with sensitive topics
• don’t diagnose or give opinion
• summarize key points of signs and symptoms
• repeat back a summary of the information
• ask open-ended and closed-ended questions
• repeat information relayed by the patient
• clarify information

Question 25

What are the 6 C’s of charting?

Answer 25

1) Client’s word - record exactly
2) Clarity - use medical terminology and precise descriptions
3) Completeness - fill in forms
4) Conciseness - saves time and space when you are recording information
5) Chronological order - date all entries
6) Confidentiality - protects patient’s privacy

Question 26

How should you document all current medications?

Answer 26

• ask to see a list or actual medications
• never ask if they’re taking the same medications as last time
• encourage patients to maintain a current list of medications