Class 5 Flashcards
What must the assessment include?
the patient’s age/sex
diagnosis or differential diagnoses
What is extra information that may be included in the assessment?
HPI elements (chief complaint and onset)
Summary of PE (relevant info only)
Summary of new labs/imaging results
Prognosis
Prognosis definition
the likely course of a disease or ailment
What is the basic structure for an assesment?
1) Age and sex
2) PMHx if relevant
3) Diagnoses
What part of the chart does the provider look at as a “note to self”?
The assessment
What does the assessment need to be?
comprehensive
What are the requirements for a test result to be written in the assessment?
1) The result is new (since the patient’s last visit)
2) The result is relevant to the Dx
How do you write test results in the assessment?
Name of the test, result of the test, why it was ordered
Example of writing a test result
An x-ray of the left wrist was negative, ruling out radial fracture
What is the plan?
A list outlining how the doctor will treat and/or monitor the patient
Normally spoken verbatim to the patient
What is the last thing that is written on the chart?
the plan
What is the form of the plan?
bullet points or numbered list
Should completed tests go in the plan?
No
Completed tests belong in the results / assessments
Future scheduled tests belong in the plan
What does the plan include?
1) Recommended treatment for each diagnosis
2) Prescriptions ordered today
3) Studies/tests/labs/imagines ordered today
4) Follow-up with other healthcare professionals
5) Follow-up here: when should the patient return for next appt?
How should treatments for different diagnoses be written in the plan?
Group treatments for each Dx together
What is the last bullet/number always in the treatment plan?
When to follow-up at that specific office
What does ICD stand for?
International classification of diseases
What does ICD Code indicate?
diagnosis
Who is ultimately responsible for choosing the ICD codes?
The providers
What needs to be true of the ICD?
every word of the ICD diagnosis must be supported by your documentation
ex: moderate persistent asthma (need to show moderate and persistent in documentation)
What is the main focus of billing as a scribe?
Accurately document the visit and the encounter
If something is left out of the chart, it is as if it did not happen!
What can happen if something is not documented correctly?
This makes it seem like it did not happen and the provider may not get reimbursed correctly
