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Health Care Admin > Chapter 10 > Flashcards

Chapter 10 Flashcards

1
Q

The medical record contains:

A
  • patient history
  • current patient health problems
  • interventions
  • communications with patients and other provides
  • billing records/ICD-10 codes
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2
Q

HIPAA

A

(Health Insurance Portability & Accountability Act)
- standard for privacy protection of health information
- applies to any group that maintains and transmits medical records in an electronic format

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3
Q

HIPAA penalties

A
  • enforced by the Department of Health and Human Services Office of Civil Rights
  • a patient has 180 days to report a violation
  • may include up to 10 years in jail & up to $1.5 million for each incident
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4
Q

HIPAA guidelines

A
  • personally identifiable information and personal health information must be protected
  • patients have the right to review their medical records
  • patient option of private treatment area
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5
Q

Documentation

A

Must demonstrate the patient’s need for skilled rehab services
- relates impairments to functional limitations

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6
Q

Impairments

A

loss or abnormality of musculoskeletal or other systems identified and measured by clinician

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7
Q

Functional Limitations

A

restriction or loss of ability to perform a certain task

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8
Q

Purpose of Documentation

A
  • provision of an accurate medical record
  • communication with referral source
  • communication with coworkers
  • communication with others involved with the patient
  • protection from liability litigation
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9
Q

Initial Evaluation - Purpose

A
  • introduce, describe, identify, and address the patients problem
  • build rapport/trust
  • introduce patient to rehab process
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10
Q

Initial Evaluation - Subjective

A

Patient interview

Includes:
- pain level
- onset
- MOI
- functional limitation
- complete medical history
- surgical history
- previous injury to same location

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11
Q

Initial Evaluation - Objective

A

quantifiable impairments measured and documented using a standardized, repeatable method in order to easily re-test to demonstrate progress in future visits

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12
Q

Initial Evaluation - Assessment

A

Contains:
- AT diagnosis
- impairments
- functional limitations
- prognosis

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13
Q

Initial Evaluation - Plan

A

Summary of the interventions needed to completely address the impairments and functional limitations listed in the assessment

Includes:
- treatment duration
- treatment frequency
- intervention list
- goals

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14
Q

Goal Writing

A

should relate an impairment to a functional limitation

includes:
- specific action to be performed by patient
- quantifiable, measurable, repeatable activity
- duration/reps of activity
- impairment that, if addressed, will allow the patient to perform the activities above
- functional limitation addressed
- timeline for goal

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15
Q

Common mistakes when writing goals

A
  • no relationship stated between impairments and functional limitations
  • no measurable outcome
  • nonspecific task
  • more than one measurable outcome
  • nonspecific activuty
  • non-descript word use
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16
Q

4 Levels of Function (goal writing) - Level One

A

the patient can perform basic ADLs without pain/symptoms, but cannot participate in recreational activities & has pain/symptoms with advanced ADLs
- goals that address endurance with daily & postural activities

17
Q

4 Levels of Function (goal writing) - Level Two

A

the patient can perform all ADLs but has pain/symptoms DURING recreational activities
- consider higher-level household chores and high-level ADLs requiring endurance

18
Q

4 Levels of Function (goal writing) - Level Three

A

the patient can perform all ADLs but has pain/symptoms AFTER recreational activities
- consider common functions in relation to how the patient can function once they are in pain after activity

19
Q

4 Levels of Function (goal writing) - Level Four

A

the patient can perform ADLS & recreational activities without pain/symptoms
- when biomechanical deficiencies are present and function is likely to be hampered in the near future
- nothing abnormal during eval and no pain or functional deficiencies

20
Q

Daily Notes

A
  • every patient visit
  • abbreviated SOAP note
  • update physician/3rd party payers on progress
  • refocuses future treatment
21
Q

Daily Notes - Subjective

A
  • pain scale
  • changes in patient function
  • patient comments
22
Q

Daily Notes - Objective

A
  • any reassessment performed
  • treatments provided
23
Q

Daily Notes - Assessment

A
  • Patient response to treatment provided at visit
  • progress made at visit
  • problems encountered
  • overall progress towards goal
24
Q

Daily Notes - Plan

A
  • changes in plan of care
  • interventions to be performed at next visit
  • assess goals
25
Q

Progress Notes

A

means by which clinicians update the physician on patient’s progress

26
Q

Progress Notes - Subjective

A

patients perspective of:
- functional improvements
- functional abilities
-pain level

27
Q

Progress Notes - Objective

A
  • results of re-evaluation
  • functional re-examination to reassess goals
28
Q

Progress Notes - Assessment

A
  • note changes in functional limitations and impairments
  • note how the patient has improved
29
Q

Progress Notes - Plan

A
  • decide what goals have been met, partially met, or not met
  • timeline for completion of goals
  • modify goals and treatment with rationale for changes
30
Q

Discharge Note

A

when a patient has:
- completed all of their goals
- no further improvements will be gained

Summary of:
- patient subjective/objective status
- statement on goals completed/not completed
- treatments performed and patient responce
- a reassessment of impairments and functional limitations
- further treatment recommendation (if any)

31
Q

Skilled Intervention

A

only billable for the time during treatment when the AT is perfecting exercise technique, form, or progress of exercises
- supervision of exercise is not billable
- technique correction is billable

32
Q

Red Flags for Reimbursement

A
  • daily intervention beyond 1 week
  • not reducing treatment frequency over the course of rehab
  • performing the same modalities throughout the course of treatment
  • modality-only treatment
  • large gaps in treatment without re-evaluation, changes in diagnosis, and change in interventions

Health Care Admin (8 decks)

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