Lecture Material Week 2

Question 1

What are some general reasons patients seek care?

Answer 1

acute problems
consultations upon request of another provider
follow up on previous illness/treatment
psychological problems
social issues

Question 2

And HPI for a follow up would shift its focus to what?

Answer 2

improvement, changes in course, new symptoms, functionality, tolerance of medicine/therapies

Question 3

What should be considered before diagnosing a psychiatric disorder?

Answer 3

Always rule out organic causes!

Question 4

What mnemonic screens for depression?

When do you employ it?

Answer 4

SIGECAPS

If pt answers affirmative for feeling down or loss of interest for at least 2 weeks

Question 5

What does SIGECAPS stand for?

Answer 5

Sleep decreased (Insomnia with 2-4 am awakening)
Interest decreased in activities (anhedonia)
Guilt or worthlessness (Not a major criteria)
Energy decreased
Concentration difficulties
Appetite disturbance or weight loss
Psychomotor retardation/agitation
Suicidal thoughts

Question 6

What does the well visit shift its attention to?

Answer 6

After addressing pt concerns:
Screenings
Immunizations

Question 7

What information would you not include in HPI presentation when presenting to a preceptor?

Answer 7

Objective

Question 8

How can you ensure understanding of the complaint?

Answer 8

Summarize information back to patient

Question 9

Why should you document as soon as possible?

Answer 9

Avoid error and recall bias

Question 10

CMS and HHS documentation guidelines include?

Answer 10

Complete & legible
Reason for visit
Hx, PE, A/P, results
Date & identity
Rationale for tests should be documented or easily inferred
Active and past problems accessible to providers
Appropriate health risk factors identified
Progress, response, and treatment changes
CPI and ICD 9 codes documented and support what is done

Question 11

True of False:

Records are subject to review by 3rd parties

Answer 11

True

Question 12

What are the uniform codes selected for level of service?

Answer 12

CPT codes

Question 13

Documentation must support….

Answer 13

diagnoses

Question 14

What is downcoding?

Answer 14

Insurance provider downgrades the encounter and reimbursement

Question 15

Rules about coding:

Answer 15

Primary codes reflect CC
code chronic conditions if they affect primary diagnoses
Never use rule…. dx use suspected instead
Don’t double code (URI and cough)
Can double code acute on chronic conditions

Question 16

A good EMR should have what qualities?

Answer 16

Health information data
Results and order management
Decision support
E-communication and connectivity
Pt support
reporting
Administrative processes

Question 17

What are some benefits to EMRs?

Answer 17

Immediate access to key info
Old and new data quickly accessible
Legibility
Reduced duplication & fragmentation
Regular screenings
Continuity
Epidemiologic surveillance
Quality management

Question 18

What are some barriers considering EMR?s

Answer 18

Computer literacy
Technology reliability (system goes down)
Cost to implement
Confidentiality
Technical issues (ease of use)
Systems adaptable to diff environments (ED, OPD)
Lack of interoperability (communication between diff places)
i.e. CCF and UH

Question 19

What does HIPAA stand for?

Answer 19

Health Insurance Portability and Accountability Act