CH 8 Medical Documentation and records

Question 1

97005

Answer 1

athletic training evalutation

Question 2

97006

Answer 2

athletic training re-evaluation

Question 3

97110

Answer 3

Therapeutic exercises

Question 4

99211

Answer 4

office/outpatient visit, est

Question 5

HCFA 1500 Clain Form

Answer 5

offical standard form used by physicians used to bill MEdicare and Medicaid for hlth servieces used for submitting claims/bills for reimbursement

Question 6

UB 04 Claim Form

Answer 6

billing format adopted by NUBC used by all hospitals for reimbursement

Question 7

Medical Record

Answer 7

contains all info about pt’s history, current problems, and interventions utilized to address those problems, as well as document record of any other form of communication

Question 8

HIPPA

Answer 8

standard for privacy protection of health information for health care providers, health plans, and health clearinghouses

Question 9

HIPPA Penalties

Answer 9

pt may file complaint w/in 180 days of violation violators can be fined up to $25000 or 10 yrs jail

Question 10

Documentation

Answer 10

reflection of quality of care that athletic trainer provides each patient

Question 11

Purposes of Documentation

Answer 11

• provision of accurate thorough medical record
• communication w/ referral source
• communicate w/ coworkers
• communicate w/ others involved w/ pt
• protection from liability

Question 12

initial evaluations

Answer 12

introduce, describe, identify, and address the pt problem; includes plan and prognosis for episode of care just begun and provides bases for tx’s

Question 13

Objectives

Answer 13

contains quantified impairments measured & documented using a standardized, repeatable method in order to easily re-test progress in future visits

Question 14

Assessment

Answer 14

includes athletic training diagnosis, impairments, func limitations, prognosis

Question 15

Prognosis

Answer 15

statemetn regarding pt’s potential for successful rehabilitation

Question 16

Plan of Care

Answer 16

summary of interventions needed to completely address impairments and functional limitations listed in assessment w/in specific time frame and demonstrate e progress

Question 17

4 levels of function

Answer 17

1- basic daily activities w/out p
2-perform all daily activities but has p
3- perform daily activities but has p after recreational activities
4- perform daily activities and recreational activities w/out complaints

Question 18

Daily Notes

Answer 18

contains subjective, objective, assessment, and plan of care data in a more limited and updated format than contained in initial eval