Chap 1 Flashcards
5 different types or groups of people who could read medical records you create:
1) attorneys, (2) researchers, (3) consulting providers, (4) patient, (5) peer reviewers, (6) insurance companies, (7) state or federal payers
List at least 5 general principles of documentation that are based on CMS guidelines.
(1) record should be complete and legible; (2) for each encounter, document reason, relevant history, exam findings and diagnostic test results, assessment, and plan for care; (3) date and legible identity of person documenting; (4) rationale for ordering test or services; (5) past and present diagnoses; (6) health risk factor identification; (7) patient’s progress and response to treatment; (8) identify CPT codes and ICD-9 codes.
Describe how to make a correction in a medical record.
Draw a single line through the entry, label it as an error, initial and date it.
Is this an acceptable or unacceptable documentation guideline: A Use of either the 1995 or 1997 CMS guidelines?
A
Is this an acceptable or unacceptable documentation guideline: Making a late entry in a chart or medical record
A
Is this an acceptable or unacceptable documentation guideline: Using correction fluid or tape to obliterate an entry in a record?
U
Is this an acceptable or unacceptable documentation guideline: Making an entry in a record before seeing a patient
U
Is this an acceptable or unacceptable documentation guideline: Amending an entry in a medical record?
A
Is this an acceptable or unacceptable documentation guideline: Stamping a record “signed but not read”?
U
T/F: CPT codes reflect the level of evaluation and management services provided.
T
T/F: The three key elements of determining the level of service are history, review of systems, and physical examination.
F
T/F: Time spent counseling the patient and the nature of the presenting problem are two factors that affect the level of service provided.
T
T/F: ICD-9 codes indicate the reason for patient services.
T
T/F:CD-9 codes are used to track mortality and morbidity statistics internationally.
T
T/F: ICD-10 code sets have more than 155,000 codes but do not have the capacity to accommodate new diagnoses and procedures.
F
T/F:“V” codes are used for reasons other than illness or disease.
T
T/F: The medical record must include documentation that supports the assessment.
T
T/F: Assignment of appropriate CPT and ICD-9 codes that support the level of E/M services provided is only dependent on adequate documentation of the history and physical examination.
F
T/F: An ICD-9 code should be as broad and encompassing as possible.
F
T/F: There is no code for “rule out.”
T
T/F: The complexity of medical decision making takes into account the number of treatment options.
T
What are ICD-9 codes used to identify?
diagnosis
symptoms
complaint
complications
rash =
exanthem
fever =
influenza
navel =
umbilicus
heartburn =
GERD
stroke =
cerebrovascular incident
kidney stones =
renal calculus
flat feet =
pes planus
B12 def =
pernicious anemia
sugar diabetes =
DM
stomach =
abdomen
tiredness =
fatigue
tennis elbow =
lateral epicondylitis
heel =
calcaneous
heart attack =
MI
pink eye =
conjunctivitis
emphysema =
COPD
light intolerance =
photophobia
tubal pregnancy =
ectopic pregnancy
ear drum -
tympanic membrane
blood thinner -
anti coag
List at least five functions that an EMR system should be able to perform.
Any of the following:
(1) store health information and data;
(2) result management for diagnostic tests;
(3) order management;
(4) decision support;
(5) electronic communication and connectivity;
(6) patient support;
(7) administrative processes;
(8) reporting.
Identify at least five perceived benefits of an EMR system.
Any of the following:
(1) immediate access to key information such as allergies, lab results;
(2) alert to duplicate orders;
(3) alert to drug interactions;
(4) reduce duplication;
(5) enhance legibility;
(6) reduce fragmentation;
(7) improve the speed with which orders are executed;
(8) alert to screenings and preventive measures needed;
(9) improve continuity of care;
(10) reduce frequency of adverse events;
(11) increase timeliness of diagnoses and treatment;
(12) provide decision-making support to increase compliance with best clinical practices.
Identify at least five potential barriers to implementing an EMR system.
Any of the following:
(1) cost of implementation;
(2) reduced workflow and productivity during implementation;
(3) unreliable technology;
(4) lack of interoperability;
(5) safety and security of systems;
(6) debate over who owns data;
(7) technical matters such as accessibility, vendor support, down time.
List at least two criteria required to meet F “meaningful” use standards.
Any of the following:
(1) certified system;
(2) electronic prescribing;
(3) quality reporting;
(4) capable of exchanging data with other systems
T/F: Establishes standards for the electronic transfers of health data
T
T/F: Provides health care for everyone
F
T/F: everyone limits exclusion of preexisting medical conditions to 24 months
F
T/F: Gives patients more access to their medical records
T
T/F: Protects medical records from improper uses and disclosures
T
T/F: Federal HIPAA regulations preempt state laws.
F
T/F: The Privacy Rule only applies to covered entities that transmit medical information electronically.
T
T/F: Protected Health Information is data that could be used to identify an individual.
T
T/F: Covered entities include doctors, clinics, dentists, nursing homes, chiropractors, psychologists, pharmacies, and insurance companies.
T
T/F: A covered entity may disclose PHI without patient authorization for purposes of treatment, payment, or its health-care operations.
T
T/F: PHI cannot be transmitted between covered entities by e-mail.
F
T/F: Patients are entitled to a listing of everyone with whom their health-care provider has shared their PHI.
F
T/F: PHI may be disclosed to someone involved in the patient’s health care without written authorization.
T
T/F: The Privacy Rule allows certain minors access to specified health care,
T
T/F: A Notice of Privacy Practice explains how patients’PHI is used and disclosed by the covered entity.
T
T/F: An employee cannot be terminated for violating the Privacy Rule.
F
T/F: An individual may not sue the insurance company over an HIPAA violation.
T
T/F: Criminal penalties for HIPAA violations can result in fines and imprisonment.
T
T/F: The confidentiality, integrity, and availability of PHI only need to be protected when the PHI is transmitted, not when it is stored.
F
T/F: Employees are required to attend periodic security awareness and training.
T
T/F: The Security Rule requires covered entities to install and regularly update antivirus, anti-spyware, and firewall software.
T
T/F: Physical and technical safeguards must be in place to prevent PHI from being transmitted over the Internet.
T
T/F: A process to develop contracts with business associates that will ensure they will safeguard PHI is required by HIPAA.
T
HIPAA may not audit a practice for compliance without notice.
F
Indicate by a yes (Y) or no (N) whether disclosure of PHI to the specific entity would require patient authorization.
N Specialist/consultant
N Patient’s health plan
Y Life insurance company
N Hospital accounting department
Y Patient’s employer
Y Pharmaceutical companies
N Reporting a gunshot wound to police
N Reporting names of patients with a communicable disease to a county health department
N Reporting suspected child abuse to a child protection agency
N Medical billing and coding department
Y Friends and family not involved in a patient’s health care
Identify at least two conditions that are considered sensitive PHI.
Any of the following:
(1) HIV status;
(2) mental health conditions;
(3) substance abuse
Patients have the right to review and obtain copies of their medical records except in certain circumstances. List two.
Any of the following:
(1) psychotherapy notes;
(2) information compiled for a lawsuit;
(3) information that, in the opinion of the health-care provider, may cause harm to the individual or another.
