Final Review Flashcards
How is billing done?
Established by number of illnesses, degree of severity, and complication of decision making
Upcoding
Billing someone for a higher level than they are assigned
Health literacy
Degree to which a person can read and interpret health information
Levels of care
1-4 from least to most severe
5 A’s of Quality of Care
- Accessible-removing structural and cultural barriers
- Affordable-free and low cost programs
- Available-map locations and identify contacts
- Appropriate-establish culturally competent services
- Accountable-assure quality of services
- Understandable-provide education to improve knowledge
4 levels of health literacy
Below basic, basic, intermediate, and proficient
What percentage of adults are proficient at health literacy?
12% of adults
Who is at high risk for low health literacy?
Elderly, minorities, immigrants, low SES, limited education
Red flags for low health literacy
Making excuses
Missing appointments and tests
No questions
Not sticking with medications
Why is health literacy a hidden problem?
People may mask the shame they feel and not talk about it, so it often goes undetected
Barriers to communication
- giving advice
- agreeing
- general statements and cliches
- defensiveness
- change subject
- disrespect
- transference
Barriers to access
Transportation Financial Medical system error (lost information) Fear and distrust Communication and lack of information
What makes a therapeutic relationship?
Trust Respect Appropriate use of power plan interactions Use active listening skills
4 problem areas-professional boundaries
Touch
Self disclosure
Gifts
Contact with clients outside work
Roles of a navigator
Address access to care needs Address emotional and practical concerns Address patients family concerns Be involved throughout continuum of care Help understand care Accompany to appointments Manage insurance problems
Difference between EMR and EHR
EMR-record of a single visit
EHR-total health, record of everything
Meaningful use
Putting the software to use
-there is an incentive program with certain required components to get reimbursed
Components of meaningful use
- CPOE (30% of patients need medications entered with this)
- drug allergy checks
- electronic prescriptions (40% all prescriptions must be transmitted electronically)
- health info (must be available within 4 BUSINESS DAYS)
- clinical summary (must be available within 3 BUSINESS DAYS)
CPOE
Computerized physician order entry
- allows providers to prescribe, order tests, and give other instructions electronically
- goal is to improve safety and efficiency
What are the 3 main elements of informed consent?
- explanation of risks and benefits
- alternative treatments
- evidence that patient or surrogate understands the procedure
Basic parts of a chart
- medical history
- history and physical of current illness
- physician orders
- progress notes
- nursing notes
- discharge summary
Documentation should include:
- date and time
- reason for encounter “chief complaint”
- history and physical
- test results
SOAP notes
Subjective-described by patient, can’t be seen
Objective-observed from physical exam
Assessment-physician assesses problem
Plan-plan for diagnosis, treatment, and education of patient
Multidisciplinary team
Have shared patient but no common goals except caring for the patient. There are various disciplines but no real communication
Interdisciplinary team
Shared goal of optimizing care and quality of life; goes from admission to discharge, and requires regular meetings
Interprofessional teams
Latest description, more cross-functional and have greater knowledge of each others’ contributions
Main reasons interdisciplinary teams are more necessary?
- aging of the population (multiple diseases)
- increasing skills and knowledge required for comprehensive care
