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
