Chapter 4 - Health Record Content and Documentation

Question 1

documentation mantra

Answer 1

the saying: “If it wasn’t documented, it wasn’t done (or didn’t happen)”; a saying used to warn healthcare professionals about the importance of documentation

Question 2

data quality

Answer 2

the reliability and effectiveness of data for its intended uses in operations, decision-making, and planning; lack of data quality can impact the quality of care a patient receives, impair the ability of the medical coder to assign the correct codes, and put the hospital in danger of lawsuits or legal penalties

Question 3

documentation standards

Answer 3

those principles, codes, beliefs, guidelines, and regulations that guide health record documentation

Question 4

template

Answer 4

a pattern used in EHRs to capture data in a structured manner and specify the information to be collected

Question 5

fraud

Answer 5

(as defined by the CMS) the intentional deception or misrepresentation that an individual knows, or should know, to be false or does not believe to be true, knowing the deception could result in some unauthorized benefit to himself or some other person(s)

Question 6

abuse

Answer 6

(as defined by the CMS) any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are priced fairly

Question 7

licensure organization

Answer 7

the legal authority or formal permission from the authorities to carry out certain activities that require such permission (e.g. the state and federal government)

Question 8

Medicare Conditions of Participation (CoP)

Answer 8

a set of standards that a healthcare organization must meet to receive Medicare funding

Question 9

Medicare Conditions for Coverage (CfC)

Answer 9

another set of standards that a healthcare organization must meet to receive Medicare funding

Question 10

deemed status

Answer 10

a status granted to an organization by the CMS; it means that that organization not only meets but exceeds expectations for a particular area of expertise

Question 11

allopathic medicine

Answer 11

an archaic term used to define science-based, conventional, modern medicine

Question 12

osteopathic medicine

Answer 12

a “whole person” approach to medicine—treating the entire person rather than just the symptoms; distinct from allopathic medicine

Question 13

statute

Answer 13

a piece of legislation written and approved by a state or federal legislature and then signed into law by the state’s governor, or the President of the United States

Question 14

authentication

Answer 14

the process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature

Question 15

auto-authentication

Answer 15

can have two meanings: (a) a procedure that allows dictated reports to be considered automatically signed unless the HIM department is notified of needed revisions within a certain time limit, or (b) a process by which the failure of an author to review and affirmatively approve or disapprove an entry within a specified time period results in authentication

Question 16

clinical data

Answer 16

the information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services; it is also the basis for the reimbursement of the treatment and ­service rendered to the patient

Question 17

medical history

Answer 17

the portion of clinical data that addresses the patient’s current complaints and symptoms and describes his or her past medical, personal, and family history

Question 18

physical examination

Answer 18

the physician’s assessment of the patient’s current health status after evaluating the patient’s physical condition

Question 19

AMA

Answer 19

acronym for “against medical advice”; a patient who leaves the hospital against the advice of his healthcare professional

Question 20

physician orders

Answer 20

the instructions the physician gives to other healthcare professionals who perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient

Question 21

standing orders

Answer 21

the orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure

Question 22

clinical observations

Answer 22

the comments of physicians, nurses, and other caregivers that create a chronological report of the patient’s condition and response to treatment during his or her hospital stay; this is usually included in the progress note

Question 23

progress note

Answer 23

an ongoing record of a patient’s illness and treatment, used to justify and coordinate further treatment

Question 24

integrated health record

Answer 24

a format used for health records in which information is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse chronological order

Question 25

care plan

Answer 25

a summary of the patient’s problems from the nurse or other professional’s perspective; it includes a detailed plan for interventions

Question 26

decedent

Answer 26

a person who has died

Question 27

pathologist

Answer 27

a scientist who studies the causes and effects of diseases, especially one who examines laboratory samples of body tissue for diagnostic or forensic purposes

Question 28

recovery room report

Answer 28

a type of health record documentation used by nurses to document the patient’s reaction to anesthesia and other conditions after surgery; also called recovery room record

Question 29

anesthesia report

Answer 29

a report that documents any preoperative medication and the response to it, the dosage of the anesthesia administered and the route of administration, the duration of administration, the patient’s vital signs while under anesthesia, and any blood products administered to the patient during the procedure, along with other relevant preoperative information.

Question 30

operative report

Answer 30

a report that describes in detail the surgical procedures performed on the patient

Question 31

pathology report

Answer 31

a report dictated by a pathologist after examination of tissue received for evaluation

Question 32

consultation report

Answer 32

a report that documents the clinical opinion of a physician other than the primary or attending physician. The consultation is usually requested by the primary or attending physician, but occasionally may be the request of the patient or the patient’s family. The consultation report is based on the consulting physician’s examination of the patient and a ­review of the patient’s health record.

Question 33

discharge summary

Answer 33

a concise account of the patient’s illness, course of treatment, response to treatment, and condition at the time of patient discharge (official release) from the hospital. The summary also includes instructions for follow-up care to be given to the patient or to his or her caregiver at the time of discharge

Question 34

transfer record

Answer 34

(used when a patient is being transferred from the acute setting to another healthcare organization) also called a referral form; a brief review of the patient’s acute stay along with current status, discharge and transfer orders, and any additional instructions will be noted

Question 35

administrative data

Answer 35

coded information contained in secondary records (such as billing records) describing patient identification and insurance. Patient registration information would be considered administrative data as would patient account information.

Question 36

ambulatory surgery centers (ASC)

Answer 36

ambulatory care facilities that perform surgery

Question 37

ancillary services

Answer 37

tests and procedures sometimes ordered by a physician; these services assist the physician with diagnosing and treating the patient

Question 38

physician office record

Answer 38

a health record created by a physician; traditionally, it refers to a record of a single physician treating a long-term patient

Question 39

Patient Driven Payment Model (PDPM)

Answer 39

a Medicare model implemented in October 2019 to improve payment accuracy by addressing each patient’s circumstances independently and classifying patients into payment groups based on specific, data-driven patient characteristics.

Question 40

Minimum Data Set (MDS)

Answer 40

part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes

Question 41

Interim Payment Assessment

Answer 41

an assessment, required by the PDPM, that must be performed when there is a significant change in the patient’s situation

Question 42

pay-for-performance

Answer 42

programs have performance measures that healthcare providers must meet or exceed to receive financial payment

Question 43

Medicare Access and CHIP Reauthorization Act (MACRA)

Answer 43

a 2015 pay-for-performance law that changed how the federal government pays physicians

Question 44

core measures

Answer 44

government-backed national standards of care and treatment processes for common conditions

Question 45

core measure compliance

Answer 45

a measure that shows how often a hospital provides each recommended treatment for certain medical conditions

Question 46

source-oriented health record

Answer 46

a health record where things are grouped together by point of origin (e.g. all of the nursing records are together, the physician notes are together, respiratory, physical therapy, lab, medications, all kept together)

Question 47

universal chart order

Answer 47

a system where the discharged patient record is organized in the same order as when the patient was on the nursing floor; eliminates the time-consuming assembly task performed by the health information department

Question 48

subjective, objective, assessment, plan (SOAP)

Answer 48

a method used to construct physician progress notes. Physicians use the acronym SOAP to remember what elements of documentation must be included in a progress note. The subjective component is patient’s complaint and a review of the medical history. The objective component is vital measurements and laboratory results. The assessment is the doctor’s diagnosis. The plan is the doctor’s treatment plan.

Question 49

problem-oriented health record

Answer 49

a style of health record created in the 1970s by Lawrence Reed; it defines and documents clinical problems individually; it consists of a problem list, the history and physical examination and ­initial lab findings (the database), the initial plan (tests, procedures), and progress notes

Question 50

document imaging

Answer 50

the process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end user

Question 51

clinical documentation integrity coordinator

Answer 51

a person who works with physicians to ensure the documentation is completed and contains enough information to assign diagnosis and procedure codes. (e.g. the documentation should identify whether the right or left radius was fractured)

Question 52

copy and paste functionality

Answer 52

a function that allows a healthcare provider to select health record documentation from one source or section of the EHR and replicate it in another source or section of the EHR; this is dangerous as it can lead to medical errors