Clinical Documentation Ch 1 & 2 Flashcards
List examples different types or groups of people who could read your medical records.
Insurance companies, consult providers, researchers, peer-reviews, attorneys, government programs that pay for care i.e. Medicare and Medicaid, and the patient
General principles of documentation based on CMS guidelines
- Complete and legible - (basically everything that needs to be included in a Focused H&P)
- Past & present diagnoses
- Risk factors
- Progress/response to txs changes and revision of diagnoses
- Codes: ICD and CPT
- Rationale
How do you make a correction in a paper medical record?
Cross it out with a single line, label it as a mistake, initial and date it.
True or false, you may use either the 1995 or 1997 CMS guidelines.
True
True or false, you cannot make a late entry in a chart or medical record.
False
True or false, you can make an entry in the medical record before seeing a patient.
False
True or false, you can use correction fluid or tape to obliterate an entry in a record.
False
True or false, it is acceptable to alter an entry in a medical record.
False
True false, it is unacceptable to stamp a record “signed but not read”.
True
3 key elements of determining the level of service.
- Hx
- ROS
- PMFSH (past medical, family and social history)
CPT codes reflect the level of __________ and __________ services provided.
evaluation; management
Time spent counseling the patient and the nature of the presenting problem are 2 factors that affect the ____________________ provided.
level of service
ICD codes - what does the acronym stand for and what do they do?
International Classification of Diseases; Indicate the reason for patient services
CPT codes - what does the acronym stand for and what do they do?
Current Procedure Terminology; used to document medical procedures that are performed
Can ICD-10 codes accommodate new diagnoses and procedures?
They can accommodate new diagnoses, but they are not responsible for procedures that would be CPT codes.
The medical record must _________documentation that supports the assessment.
include
Good documentation is absolutely essential to support the level of _______ services and facilitate assignment of __________ CPT and ICD codes.
E/M (evaluation and management); correct
True or false, an ICD code should be as broad and encompassing as possible.
False
There is no ________ for “rule out”.
Code
The complexity of medical decision making takes into account the ______________ of treatment options.
number
ICD codes are used to identify what?
Diagnosis, complaints, symptoms and conditions
List 5 benefits of and EMR system.
- Immediate access to key info
- Faster diagnosis and treatment
- Improve legibility
- Notifications of drug interactions
- Decrease duplications
List the 8 functions an EMR system should be able to perform.
- Health information and data
- Result management
- Order management
- Decision support
- Electronic communication and connectivity
- Patient support
- Administrative processes
- Reporting
List 5 barriers to implementing an EMR system.
- Cost
- Safety & security systems
- Concern over ownership of data
- Ease of use and customer service
- Computer literacy
List 2 criteria required to meet “meaningful use” standards.
- Qualified system
- Ability to exchange data with outside systems
Covered entities according to HIPPA include?
Chiropractor, nurse practitioner, doctor, Medicare, hospital, health maintence organization (HMO), preferred provider organization (PPO), Medicaid, psychologist, nursing home, and veterans affairs (VA) hospital
Identify conditions that are considered sensitive PHI.
Mental health issues, HIV status, substance abuse disorders
