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Documentation > Lecture 3 > Flashcards

Lecture 3 Flashcards

1
Q

Trendy and popular words that come and go, some can be red flags while others are looked for by payor source.

A

Buzzwords

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2
Q

Abbreviation purpose =

A

communication

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3
Q

words specific to a group of people

A

Jargon

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4
Q

ways to shorten a word

A

Abbreviations

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5
Q

Be concise, keep sentences short and watch your jargon

A

Clarity

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6
Q

Documentation must be factually correct, done chronologically, and consistent with protocol. Should be done timely.

A

Accuracy

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7
Q

Write only what needs to be written, why OT was needed, what outcomes were achieved or worked towards,

A

Relevance

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8
Q

Unusual occurrences and events and what you did about it. Non compliance or refusal, why you deviated from the care plan.

A

Exceptions

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9
Q

Common errors in documentation

A

Unclear, too much or inappropriate jargon or abbreviations Failing to document
Missing documentation
Poor grammar and spelling
Wrong chart
Late documentation

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10
Q

How to correct a mistake

A

Addendum

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11
Q

an addition or revision to the note
Make an addendum or put a pen line through it
Make sure it has the date, the correction, why you’re making the change, initials

A

Addendum

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12
Q

Any ID of patient
Required ethically by AOTA
HIPAA

A

Confidentiality

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13
Q

Health insurance portability and accountability act
Rights, companies rights, complaints, contracts

A

HIPAA

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14
Q

Physician/pt privilege
Record/Therapy is confidential
Varies from state to state

A

Confidentiality law

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15
Q

Must have ok from patient in writing
Exceptions: peer reviews, legal procedures, request of govt, research protocol. Records are retained for 5 years or until the pt is 21.

A

In order to disclose information

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16
Q

Family education rights and privacy act of 1974

All documents that contain a student’s name, address, phone number, parents name, or identifying information.

A

FERPA

17
Q

Keeping Files

A

Locked cabinets, copies must be secure
State law varies: statute of limitations for malpractice
Usually 5-10 years (til their 21 for children)
Shredded or burned to dispose of them

18
Q

General precautions for Documentation

A

Do not change record without clarification
Beware of signatures
Avoid criticism to pts and other healthcare workers Avoid subjective comments about pt or pt family Use time stamps
Follow a sequence
Use proper grammar/abbreviations

19
Q

Knowingly, willfully, and intentionally misrepresenting (lying) about the facts. “Up-coding” billing for things you didn’t do

Seeing a pt you never saw
Accepting kickbacks

A

Fraud

20
Q

practice that is inconsistent with sound medical or business practice Over utilizing services

Excessive billing

A

Abuse

21
Q

6 acts medicare prohibits

A

Making false claims
Making false statements for payment
Billing for visits never made
Billing for non face to face therapy sessions
Paying for or receiving kickbacks for goods and services Paying for referrals (soliciting for referrals)

22
Q

Medicaid anti-fraud and abuse amendments

Established penalties for:
Knowingly and willingly making false statements to receive payment or benefits Knowingly concealing an event that could affect payment
Knowingly or willingly using someone else’s benefits or accepting someone else’s benefits.

A

Medicare

23
Q

knowingly accepting payment (cash or gifts) for referrals
requires intent

A

Anti-Kickback statute of 1980

24
Q

prohibits physicians from referring to a lab if they have or a family member has a relationship with that lab

A

Physician self referral Law of 1990 (stark 1)

25
Q

Extended this same law to OTs, PTs, RT, DME, Home health services, Drugs, hospitals, prosthetics and orthotics.

different from the kickback laws because they do not require intent

A

Stark 2 law of 1993

26
Q

Expecting to stark laws

A

no direct tx from physician, separate building

27
Q

Safe harbor regulations

A

Set up to protect legitimate business relationships

28
Q

3 strikes you’re out law
Hospitals must provide a list of all rehab and DME in the area

A

Balanced budget act of 1997

29
Q

Commission of Standards and Ethics

A

Enforce the policies

30
Q

3 members (act as court)
Jurisdiction over AOTA members
Ethical issues
Punishment

A

Judicial council

31
Q

legal issues; police of profession before entering profession

A

NBCOT

32
Q

state licensure board

A

ASBOT

33
Q

Action involving a letter

A

Reprimand

34
Q

When public disproves

A

Censure

35
Q

Action requiring removal

A

Suspension

36
Q

permanent removal

A

Revocation

37
Q

Grounds for discipline by NBCOT/ASBOT

A

Incompetence, unethical behaviors, mentally/physically impaired

38
Q

General jurisdiction

A

AOTA
NBCOT
state boards

Documentation (4 decks)

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