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WEEK 2/3 (MOD 3) > Clinical Documentation > Flashcards

Clinical Documentation Flashcards

1
Q

found in medical record chart along with (administrative documentation)

A

Clinical Documentations

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2
Q

Clinical Documentations includes services and procedures which are the ff :

A

— Patient encounter
— Pathology & laboratory testing
— Diagnostic studies
— EKGs

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3
Q

Clinical Documentations various formats & types of reports :

A

— History & Physical (H&P)
— Progress notes
— Consultation report
— Orders
— Operative reports
— Radiology / Nuclear Medicine Reports
— Discharge Summary

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4
Q

What is a History & Physical (H&P)?

A

information pertaining to the patient’s health history and current condition

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5
Q

What are progress notes?

A

documentation of a patient encounter

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6
Q

What is a consultation report?

A

includes physical examination, test results, and along with the consultant’s expert opinion about the PT’s condition

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7
Q

What is an order(s)?

A

a request made by the provider to receive services, labs, diagnostic tests, therapies, or medication (without an order these services cannot be performed); this includes dx statement to why the order is needed

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8
Q

What are Operative reports?

A

surgeon dictated report containing details about the procedure performed (why was it necessary, operative findings, and the condition of the pt at the end of the procedure

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9
Q

What are Radiology / Nuclear Medicine Reports?

A

a report written by the radiologist which describes the findings and assessment of radiology films or nuclear medicine tests

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10
Q

What is a Discharge Summary?

A

summary of an inpatient or surgical encounter including :
— Last face-to-face encounter
— Physical exam
— Review of medications
—Discharge orders for home health or physical therapy
— Any other instructions for the pt

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11
Q

What is clinical concepts?

A

essential to medical codes used for billing and reporting

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12
Q

What are some examples of clinical concepts?

A

— Anatomy
— Complicated by
— Episode
— History of
— Severity
— Symptoms

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13
Q

What are code assignments often made by?

A

by using the search feature only the relevant key terms were used

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14
Q

What are the standard code sets and what are they used for?

A

terminology standards & SNOMED-CT — used for clinical documentation
CPT, ICD-10, HCPCS — used for billing

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15
Q

What are examples of terminology standards and what are they for?

A

— Logical Observation Identifiers Names and Codes (LOINC) - for laboratory tests, measurements, and observations
— National Drug Code (NDC) – for drugs
— Centers for Disease Control (CDC) and Prevention – vaccines administered
— use of abbreviations & acronyms

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16
Q

maintains a list that is not recommended for use, because of the potential causing medical errors

A

Joint Commission

17
Q

— classify medical treatments, tests, procedures, supplies & equipment, and diagnoses identified in medical records
— used in EHR transactions for billing and for research & population health management
— regulated by HIPAA Administrative Simplification

A

Code Sets

18
Q

ICD-10

A

includes both ICD-10-CM for diagnosis codes and ICD-10-PCS for inpatient procedure codes

19
Q

CPT

A

outpatient services/procedures

20
Q

HCPCS

A

services not included in CPT

21
Q

CDT

A

dental procedures

22
Q

NDC

A

drug products

23
Q

This is the medical code sets US primarily uses for reporting & billing purposes…

A

HCPCS (Level I codes and Level II National Codes) and ICD-10-CM and ICD-10-PCS

24
Q

It has direct correlation to these primary code sets because they have assigned values…

A

Revenue Cycle

25
Q

RBRVS stands for…

A

Resource-based Relative Value Scale

26
Q

What does RBRVS do?

A

— this is where foundation for valuation of codes comes from
— used to calculate payment for professional services.
— assigns value to CPT & HCPCS Level II

27
Q

What are the 3 components RBRVS based assigning value to CPT & HCPCS Level II?

A

— time or amount of work performed by the provider
— overhead cost of the practice to provide service
— expense of medical malpractice or professional liability coverage

28
Q

SNOMED-CT stands for…

A

Systematized Nomenclature of Medicine-Clinical Terms

29
Q

What does SNOMED-CT do?

A

Allows data to be abstracted regardless of different terms or phrases used

WEEK 2/3 (MOD 3) (3 decks)

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