Medical Records Flashcards
File is divided into two sections with one for progress notes and one die diagnostic reports
Source oriented medical record
File has patients problems listed on a form at the front of the chart and when problem occurs the number and problem is noted
Problem oriented medical record
Format involves fist documenting chief complaint along with symptoms (subjective) m, followed by physicians findings (objective), the diagnosis (assessment), treatment, tests, education, and follow up (plan)
Subjective objective assessment plan (soap)
Cms 1500 form
Form Used for billing physician services provided in an outpatient setting. Medicare part b services are reported using this form
CPT
Current procedural terminology
Hcpcs
Healthcare common procedure coding system
Cms 1450 form
Used for submitting healthcare facility claims Medicare part A services are reported using this form
Medicare conditions of participation
Cops
CFCs
Conditions for coverage
Ipps
Inpatient prospective payment system -used for acute care hospital admissions
MS-DRGs
Medicare severity diagnosis related groups (identify set payment amount based on average cost of specified groupings of procedures and diagnoses
Uhdds
Uniform hospital discharge data set - standard data set adopted by government for collection of data for Medicare and Medicaid
RBRVS
Resource based relative value scale physician fee schedule implemented by Medicare in 1992. Payment system uses relative value for physician services and is based on commonly used resources for each level of service
HHPPS
Home health prospective payment system- consists of various base payments which are adjusted for care needs and patient health condition
OASIS
Outcome and assessment information set -used to document an assesment of the patient
