Ch. 2: The Health Record Flashcards
What is abstracting?
extracting data from the health record
What is the chief complaint?
the reason, in the patient’s own word, for presenting to the hospital
What is comorbidities?
preexisting diagnoses or conditions that are present on admission
What is a consultant?
healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester
What is a healthcare provider?
person who provides care to a patient
What does hybrid mean?
a combination of formats producing similar results (i.e. paper and electronic records)
What does integral mean?
essential part of a disease process
What is a physician?
licensed medical doctor
What is a principal diagnosis?
the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
What are progress notes?
daily recordings by healthcare providers of patient progress
Every patient encounter must have a health record (True/False)
True
The operative report should be written or dictated immediately following the procedure (True/False)
True
List five purposes of a health record.
- describes a patient’s health history, 2. serves as a method of communication for health care professionals, 3. serves as a legal document, 4. serves as a data source, 5. serves as a resource for health care education
Name an advantage of an electronic patient record.
multiple users can access the record at the same time
Name the nonfederal organization that requires reporting of data collected from the health record.
The Joint Commission, previously known as the Joint Commission on Accreditation of Healthcare Organizations
List five elements requirements by the UHDDS.
personal identifier, date of birth, sex, race and ethnicity, residence, hospital ID, admit date, type of admit, discharge date, NPI of operating and attending physician, diagnoses, procedures and dates, external cause of injury, birth weight of neonate, disposition of patient, source of payment, charges
Where in the record would you find the chief complaint?
The chief complaint cant be found in almost any progress note but is most often found in the Emergency Record or in the Admission History and Physical. It is the reason in the patient’s own words for presenting to the hospital.
If a physician was treating a patient with an antibiotic, where in the record would you look to see that treatment had been discontinued?
The physician orders or medication administration report (MAR) would be the place to look for the discontinuation of drugs.
Where in the record would you expect to see how the patient was progressing on a daily basis?
The progress notes would show a patient’s daily progress in the hospital.
Where in the record might you look to find how much blood was lost during surgery?
The anesthesia record and operative report will contain documentation of blood loss during surgery
What is the most important definition a coder should know?
The definition of principle diagnosis is “the condition after study found to be chiefly responsible for occasioning the admission to the hospital.”
What determines an MS-DRG?
The MS-DRG is driven by the principal diagnosis along with the principle procedure.
What is the principal diagnosis in the following scenario?
A patient is admitted to the hospital with extreme indigestion. A workup ensues, and the patient is found to have GERD (gastroesophageal reflux disease). Three days later, on the day of discharge, the patient is unable to speak. After undergoing MRI, the patient is found to have had a stroke.
GERD
A patient is admitted to the hospital with an asthma attack. On his last admission 3 years ago, the diagnosis was community acquired pneumonia. Is the pneumonia coded and why or why not?
No, the pneumonia is not coded because it is no longer an active condition that is being treated.
List five reasons why a secondary diagnosis might be reported.
If the secondary diagnosis meets one of the following criteria, it should be coded as clinical evaluation, therapeutic treatment, diagnostic procedure performed, extended length of the hospital stay, or increased nursing care or monitoring
The physician documents seizure disorder in the patient’s past medical history. The patient is receiving Tegretol, according to the list of medications. Should the seizure disorder be coded, and why or why not?
Yes, a code should be assigned for seizure disorder because the patient is currently being treated with Tegretol.
A patient has urinary retention after undergoing surgery documented in progress notes. The attending writes an order for the nursing staff to record urine output. The nurse inserts a Foley catheter. Should the urinary retention be coded, and if so, why or why not?
Yes, urinary retention is documented by the physician and is requiring increased nursing care by monitoring urinary output and insertion of a Foley catheter.
If a patient is not on any drugs for Parkinson’s, should a code be assigned for this diagnosis and why or why not?
Yes, because Parkinson’s disease is one of the chronic conditions that are reported because patients are evaluated or monitored even though they are not specifically treated.
If a patient presents with diarrhea and vomiting and the attending physician determines this to be gastroenteritis, what diagnosis/diagnoses should be assigned?
just the gastroenteritis because the diarrhea and vomiting are symptoms of gastroenteritis
Which is the principal procedure, when a diagnostic procedure is performed for the principal diagnosis and a therapeutic procedure is performed for definitive treatment of a secondary diagnosis?
The diagnostic procedure is the principal procedure.
When coding a record, where is the best place to begin?
The discharge summary, if available, because it summarizes the events of the hospital stay
If the discharge summary includes a list of diagnoses, should the coder choose the first in the list as the principal diagnosis?
No (or not necessarily). The coder must abide by the definition of principal diagnosis. Especially during a long stay, a physician might list the most current diagnoses rather that the reason the patient was admitted
What does TJC stand for?
The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
What does UHDDS stand for?
Uniform Hospital Discharge Data Set
Which report in the record must be on the record within 24 hours?
Operative Report and Admission History and Physical
What does the term “integral” mean?
It means that if a condition is routinely associated with a disease process, it is not coded separately.
Where in the record would a coder find the admitting diagnosis?
The emergency record, if applicable, or in the physician’s admission orders or history and physical
Name one reason why a coder would query a physician.
Reasons for querying could include unclear or questionable diagnosis, evidence of treatment but no diagnosis, to determine if a condition is due to a postoperative complication, to determine if an organism is the cause of a disease, to determine a more specific site or diagnosis, of for POA status
The best place in the record to find the patient’s history is in the ()
History of the present illness (H&P) and past medical/surgical history (H&P)
The beginning of the patient’s story is usually the discharge summary. True/False
False. The beginning of a patient’s story is often the Emergency Record or the Admission History and Physical
It is permissible for a coder to use documentation provided by an interventionalist. True/False
True. An interventionalist is a physician.
Once a physician answers a coding question, it should be thrown in the trash.
False. When a physician answers a query, this should become a permanent part of the record.
Physician queries should only have enough room for a physician to sign and date True/False
False. There should be room for signing and dating as well as response; coder ID, and patient information such as name, MRN, admit date, and date of query.
When a coding question is asked, it is very important that the financial impact of the response is included. True/False
False. This should never be included.
It is important that the date and the identity of the physician be included for every note. True/False
True
It is important for the record to include documentation that supports a code used in billing. True/False
True
Documentation from a physician consultant cannot be used to assign codes. True/False
False. A consultant is a medical doctor.
A principal diagnosis is one of the elements that determine an MS-DRG. True/False
True
An example of a diagnostic procedure is an MRI. True/False
True
Surgery can be a form of therapeutic treatment. True/False
True
