Chap 6

Question 1

What do you do if a patient is non compliant?

Answer 1

You must document this

Question 2

What are active problems?

Answer 2

Active problems include current or chronic conditions that require ongoing management or further workup

Question 3

What must be documented with each problem?

Answer 3

The date of onset and the International Classification of Diseases, 9th Revision (ICD-9)

Question 4

What are inactive problems?

Answer 4

Inactive problems are those that occurred in the past but are now resolved and can be either medical or surgical.

Question 5

Upon receiving a hospital discharge summary what do you need to do?

Answer 5

any newly diagnosed conditions or surgeries should be added to the list.

Question 6

What is put on the medication list?

Answer 6

All prescription and nonprescription medications should be listed. It is important to include herbal products, vitamins, minerals, dietary supplements, or other regularly used over-the-counter (OTC) products.

Question 7

What does a medication list help with?

Answer 7

A comprehensive list will alert the provider to possible drug-drug or drug-herb interactions. It will also help to avoid duplication

Question 8

What should be included for each medication?

Answer 8

The list should include the name of the medication, indication, strength, and dosing directions

Question 9

What do you do if a med is discontinued?

Answer 9

When a medication is discontinued, it is helpful to indicate the date and reason why directly on the medication list.

Question 10

Should medication allergies be listed on the medication chart?

Answer 10

YES, as well as specific reaction

Question 11

When do you use a flow sheet?

Answer 11

Many chronic medical conditions require regular monitoring of certain parameters. The frequency of monitoring depends on whether the patient is stable or unstable.
Use it for labs and treatments!!

Question 12

What are some unintentional barriers to compliance?

Answer 12

Some unintentional barriers to compliance may be the patient’s culture, language, religious practices or beliefs, or socioeconomic factors.

Question 13

What could a patients failure to improve mean?

Answer 13

Failure to improve could mean that the patient has not been correctly diagnosed, the correct treatment has not been initiated, or the patient has not been compliant with the recommended treatment.

Question 14

Where do we document noncompliance?

Answer 14

“Noncompliance” should be documented in the assessment and on the problem list.

Question 15

What do we have to document with a noncompliant patient?

Answer 15

Any advice or education provided should be documented in the plan

Question 16

What is the minimum you should document for billing information?

Answer 16

At a minimum, you should document the patient’s full legal name, address, telephone number, and date of birth.

Question 17

What should we not use to identify the patient?

Answer 17

SSN

Question 18

Where do you keep billing information?

Answer 18

It is generally recommended that billing information and any correspondence regarding billing and payment issues be kept separate from clinical data.

Question 19

How are lab and imaging tests filed?

Answer 19

chronologically, most recent first

Question 20

Why is it important for the referring doctor to say why the pt is being referred?

Answer 20

so that the consulting provider knows whether to provide an opinion only or to manage the patient’s condition actively.

Question 21

In order to send medical records from one facility to another what is required?

Answer 21

To ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations, a signed release of information is required to release any medical records from one facility or provider to another.

Question 22

What are health care advanced directives?

Answer 22

documents that communicate a person’s wishes about health-care decisions in the event the person becomes incapable of making health-care decisions.

Question 23

What are the types of advanced directives?

Answer 23

living wills and health-care power of attorney

Question 24

What is a living will?

Answer 24

A living will expresses a person’s preference for medical care.

Question 25

When do living wills come into effect?

Answer 25

when the patient has lost capacity to make health-care decisions and that patient has a particular condition, such as a terminal illness or permanent unconsciousness.

Question 26

What do you need for a living will to be valid?

Answer 26

A living will should be signed, dated, and witnessed by two people. Some states require a notary or permit a notary in lieu of two witnesses.

Question 27

What is a POA?

Answer 27

Power of attorney
a document in which one person (the patient, or principal) names another person (the agent, attorneyin-fact, or proxy) to make decisions about health care.

Question 28

What is the difference between a POA and a living will?

Answer 28

A POA differs from a living will in that it focuses on the decision-making process and not on a specific decision.

Question 29

What do you document in a phone call?

Answer 29

Date and time of the call, patient’s name, name of caller and relationship to the patient, the complaint, advice given, follow-up plan, and disposition. The advice should be documented in detail

Question 30

What do you leave on the answering machine if they do not pick up?

Answer 30

The provider should never leave clinical information or advice on an answering machine; instead, leave only a name (without title) and phone number, and request a call back.

Question 31

What is a big disadvantage of using email as a source of communication with patients?

Answer 31

One of the most frequently cited disadvantages is related to revenue.