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Chapter 3: Office Administration > Chapter Review > Flashcards

Chapter Review Flashcards

1
Q

What is SOAP?

A

Charting format that uses subjective, objective, assessment, and planning to organize the information.

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2
Q

What does the SOAP method consists of?

A

Subjective impressions, Objective clinical evidence, Assessment or diagnosis, and Plans for the future of the patient.

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3
Q

What does the subjective data includes?

A

The patient’s explanation of the problem and perception of pain.

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4
Q

What information does the objective clinical evidence contain?

A

Physical exam, laboratory results, and radiological information.

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5
Q

What is the assessment?

A

It is the diagnosis of the disease.

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6
Q

What does the plan section include?

A

Treatment, management of disease, therapy, and any ongoing patient plans.

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7
Q

What is POMR?

A

Problem Oriented Medical Records that divide records into four sections - the database, problem, treatment, and progress.

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8
Q

What does the database includes?

A

Information such as the patient’s chief complaint, symptom review, physical examination data, laboratory reports, and profile.

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9
Q

What does the problem contain?

A

List of the patient’s problems that require management, with each problem is numbered and titled.

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10
Q

What does the treatment section includes?

A

Plans for treatment of the patient’s problems, including therapy and other assistance. These are also numbered and titled.

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11
Q

What does the progress section includes?

A

Notes that are numbered to match the patient’s problems.

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12
Q

What are paper-based records?

A

Are prepared for filing and storage by performing five steps: conditioning, releasing, indexing and coding, sorting, and filing.

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13
Q

What does conditioning files includes?

A

Removal of any attached metal, such as pins, staples, and paper clips.

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14
Q

The release of a document is -

A

Performed by marking a mark - such as a stamp or the medical assistant’s initials - on the medical record to show that the paperwork is ready for filing.

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15
Q

Indexing and coding consists of -

A

Organizing paperwork added to the file.

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16
Q

Sorting and filing paperwork -

A

The items should be added to the medical record face-up, with the top edge to the left and the most recent data on the top.

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17
Q

What are the three filing methods?

A

Alphabetical by name, numerical, or by subject.

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18
Q

What is the simplest filing method?

A

Alphabetal filing

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19
Q

Open office scheduling system

A

Most often used in medical facilities that offer urgent care, where time is governed more by needs of patients than adherence to a schedule.

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20
Q

What are the types of scheduled appointments?

A

Self-scheduling, wave scheduling, cluster scheduling, and advance booking.

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21
Q

Self-scheduling appointment system

A

Enables patients to be able to schedule their own appointments 24 hours a day via their computers.

22
Q

Wave scheduling

A

Has all patients to be seen in an hour scheduled to arrive at the beginning of the hour and are then seen in the order of their arrival.

23
Q

Cluster scheduling

A

Has patients with similar problems or procedures book consecutively.

24
Q

Advance booking

A

Refers to appointments that are scheduled months in advance, such as routine physicals or follow-up appointments.

25
Q

Privacy Rule

A

A national standard to protect a patient’s medical record and health information.

26
Q

Security Rule

A

A national standard that requires health care professionals to take specific technical precautions to ensure that patient information store or transmitted in an electronic format remains confidential, accessible, and of a high quality.

27
Q

Durable supplies

A

Supplies that are expensive and not often replaced such as fax machine, computers, examination tables, EKG machines, and copiers.

28
Q

Non-durable supplies

A

Supplies that are inexpensive, and often used and replaced such as pens, paper, and paperclips, gauze, tongue depressors, and tape.

29
Q

Controlled substances

A

Medications or substances listed by schedule and controlled under the Controlled Substance Act according to the potential for addiction or medical use.

30
Q

Diagnosis codes are used for

A

Medicare and other insurance reimbursement in an outpatient setting.

31
Q

Diagnosis codes as currently referred to as

A

ICD-9-CM coding and classification system.

32
Q

How often are the ICD-9-CM numbers published and when do they become effective?

A

Yearly and becomes effective October 1 after a twice-yearly review by the National Center for Health Statistics and the Administrator for CMS.

33
Q

What does CMS stands for?

A

Centers for Medicare and Medicaid Services

34
Q

Federal Register

A

The official daily publication for rules, proposed rules, and notices of federal agencies and organizations.

35
Q

How many Volumes does the ICD-9-CM consists of?

A

3 and is available in various media formats including printed text, CD, and downloadable file.

36
Q

What is Volume 1?

A

It is the Tabular List and contains five appendices, V codes, E codes, and 17 chapters.

37
Q

Tabular List

A

Volume 1 of the ICD-9-CM containing disease information. Organized by disease and injuries according to etiology and organ systems.

38
Q

What is Volume 2?

A

Alphabetic index contains the same diseases and conditions in alpha order and is divided into three sections; an index of disease, poison and external causes of adverse effects of drugs and other chemical substances; and an alphabetic index of external causes of injury and poisoning.

39
Q

What is Volume 3?

A

Contains an alphabetic and tabular index of procedures primarily used in hospitals. The procedure codes are two digits follow by a decimal and one or two digits.

40
Q

What is the purpose of the steps for ICD Coding?

A

To help ensure that the appropriate code is assigned.

41
Q

The first diagnosis coded is the -

A

Problem that brought the patient to the office or the one that demanded most of the physician’s effort.

42
Q

CPT Codes

A

Are used in physician’s practices for services and procedures on claim forms for payment from Medicare and many insurance companies. It is also used to ensure medical necessity of services and procedures and to measure physician productivity.

43
Q

What does CPT stands for?

A

Current Procedural Terminology

44
Q

CPT is published by the -

A

American Medical Association (AMA)

45
Q

How many digits does the CPT contain? and what is it used to describe?

A

5 digit code and is used to describe medical, surgical, radiology, laboratory, and anesthesiology.

46
Q

Approximately how many CPT codes ranges from 00100 through 99499?

A

7,800 CPT codes

47
Q

How many categories is the CPT code divided into?

A

3 categories

48
Q

Category 1 codes

A

Are the current procedure codes and are developed by the AMA.

49
Q

Category 2 codes

A

Are designated for physicians to track services that have been determined to assist with quality care. Also cover any supplies or services not covered by Category 1 and are optional. It is a five digit code with an “F” in the fifth digit slot.

50
Q

Category 3 codes

A

Are temporary codes used to identify new technologies.

51
Q

How many sections is the CPT code broken down into?

A

6 sections

52
Q

What are the 6 sections that the CPT code is broken down into?

A

Evaluation and Management, Anesthesia, Surgery, Medicine, Pathology and Laboratory, and Radiology.

Chapter 3: Office Administration (2 decks)

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