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Medical Communications > Outpatient Documentation > Flashcards

Outpatient Documentation Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the 6 types of outpatient visits?

A
  1. Physicals
  2. Specialty physicals
  3. Problem focused
  4. New patient - establish care
  5. Hospital follow-up
  6. Chronic condition - follow-up
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2
Q

Which are the top 2 venders for the EHR?

A
  1. Epic
  2. Cerner
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3
Q

According to a 2017 Annals of Internal Medicine study, for every ___ hour(s) providers spend in direct clinical face time to patients, nearly _____ additional hour(s) is spent on EHR and desk work within the clinic day.

A

1; 2

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4
Q

According to a 2017 Annals of Internal Medicine study, providers spend another _____ hour(s) of personal time each night doing additional computer and other clerical work.

A

1 to 2 hours

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5
Q

Documentation of the individual patient encounter = ____

A

SOAP note

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6
Q

Other outpatient documents (not the SOAP note), are important to:

A
  1. Provide continuity of care
  2. Preserve information for future management of patient
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7
Q

What is included in outpatient documentation?

A
  1. Problem list
  2. Medication list
  3. PMH - medical, surgical, past medications, OB/GYN
  4. Social history/Family history
  5. Health maintenance - screenings, vaccinations
  6. Allergies
  7. Lab & Diagnostic testing results
  8. Communications - to/from patient, FMLA, to/from other providers
  9. Hospital notes, consultation notes, urgent care notes, walk-in-clinic notes
  10. Demographic and billing information
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8
Q

How are paper charts organized?

A

Each subdivision should appear in chart with most recent on top
- Left side of folder: Patient Summary Sheet, contact info, and HIPAA forms
- Right side of folder:
1. Patient encounter notes (SOAP notes)
2. Laboratory notes
3. Imaging results
4. Consult notes/referrals
5. Patient correspondence

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9
Q

Ultimately, whose responsibility is it to ensure that the information in the patient’s chart is up to date and accurate?

A

YOURS (the provider’s)

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10
Q

What subdivision of outpatient documentation provides summary of key elements of patient’s health history?

A

Problem list

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11
Q

T/F Problems listed in the “Problem List” portion of outpatient documentation are either active or inactive.

A

T
Active - current or chronic conditions
Inactive - occurred in past but are now resolved

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12
Q

For a current or chronic condition to be considered an “active problem” in the Problem list, it must require one of the following:

A
  1. Ongoing management (I.e. meds, specialist f/u)
  2. Periodic screening (I.e., colon polyps, breast cancer)
  3. Periodic lab/diagnostics (I.e. CKD, hyperlipidemia)
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13
Q

How often does the problem list need to be updated?

A

The problem list requires viewing and updating at each visit AND whenever a test result, lab result, consult note, and hospital note is received

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14
Q

T/F Medication List for outpatient documentation only includes prescription meds.

A

F - should include ALL prescription and nonprescription meds (be sure to ask about regularly used OTC products)

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15
Q

What needs to be included in the medication list?

A
  1. Name
  2. Indication
  3. Strength
  4. Sig (how it’s taken) - “Sig” is short for Latin word, “signetur”, or “let it be labeled”
  5. Prescriber - may note physician’s name or just “prescribed elsewhere”
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16
Q

What would you document/list for a medication that was discontinued?

A
  1. Date &
  2. Reason why it was discontinued
    - unless obviously for short term use as with an antibiotic)
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17
Q

What should be included when documenting allergies to medications?

A
  1. Specific reaction - rash, anaphylaxis, cough, nausea
    - many items listed aren’t true allergies but are adverse reactions
  2. Include allergies to other substances such as latex, nickel, red dye
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18
Q

T/F Many items listed aren’t true allergies but are adverse reactions.

A

T

19
Q

ALWAYS _____ med list at every visit

A

reconcile

20
Q

What is included in the patient’s PMH for outpatient documentation (IT’S MORE THAN A SOAP NOTE!)?

A
  1. Medical conditions
  2. Surgeries
  3. Hospitalizations
  4. Health maintenance (vaccinations, screening)
21
Q

Some EMRs have ______ to pharmacies and outside laboratories/imaging centers in which data auto-populates into chart.

A

automatic interface

22
Q

What does “automatic interface” mean?

A

Data auto-populates into chart; some EMRs have automatic interface with pharmacies and laboratories/imaging centers

23
Q

T/F Imaging reports, not actual images, are kept in the medical record.

A

T - some imaging center will provide access for providers to look at actual images

24
Q

Who’s responsible for communicating results to the patient?
A. The ordering provider
or
B. Lab/imaging facility

A

A. The ordering provider ALWAYS (including critical results - lab/imaging center will call ordering physician’s office directly)

25
Q

How are critical results delivered to the ordering provider?

A

Critical results will be called directly to ordering provider’s office
- may be called to answering service
- it is then YOUR responsibility to communicate to the patient!!!

26
Q

What should be included when communicating lab results/diagnostic testing to patient?

A
  1. What the results were in lay terms (normal, acceptable, high, low)
  2. When or if follow up is needed - additional lab work or imaging, repeat lab work or imaging, whether or not referral is to be made
  3. Instructions associated with results
  4. Any medication changes recommended
27
Q

What are some acceptable methods to communicating lab/imaging results to patients?

A
  1. Phone call from medical assistant
  2. Phone call from provider
  3. Patient portal; portal messaging
  4. Email - HIPAA concerns
  5. Snail mail - some patients request this; document the mailing
    - letter for annual physical - include personal note
28
Q

T/F Telling the patient that you suspect cancer, even if it is true, before having the biopsy result is an appropriate form of communication about expectations to the patient.

A

F - not using caution when reporting to patient in this way. Provide reassurance to patient but be sure they understand what is expected from them in terms of the ‘next step’.

29
Q

What does the referring provider include in a referral to a consulting provider?

A
  1. Must specify the reason for the referral and the action desired
  2. In outpatient setting, typically implies that the consulting provider will take over the management of that condition (not merely requesting an opinion)
  3. Typically sends last 2-3 encounters related to that ID-10 for which referral being made along with any lab/imaging results
    - If referring provider deems that the condition requires patient needs to be seen immediately, he/she may call consulting provider directly or send patient to the ED (call consulting provider to see if he/she has the proper equipment the patient needs for condition)
30
Q

What is the expectation of the consulting provider upon receiving a referral for a patient?

A
  1. Expected to communicate back to referring provider in a timely manner
  2. Authorization for referring provider and consulting provider to discuss case is implied with the referral
  3. Consulting providers will typically call the referring provider if condition evaluated requires immediate treatment
31
Q

The _______ maintains responsibility for the overall health care of the patient even when the patient is under a specialist’s care.

A

primary care provider

32
Q

If able to get ______, they may be invaluable in filling in details and providing insight into patient’s PMH as well as save time and money if able to access prior lab results or diagnostic studies.

A

prior medical records

33
Q

Helpful to have admission _____ and _____ for a hospital follow-up appointment. Why?

A

H&P; discharge summary
- Helps ensure continuity of care

34
Q

T/F Obtaining an admission H&P and discharge summary for a hospital follow-up requires a signed release of information

A

T - HIPAA

35
Q

What are the nature of most calls for an outpatient office?

A
  1. Request for refills
  2. Request for medical advice - “dial a doc” vs. telemedicine
  3. Request for test results
36
Q

What are office protocols for telephone communications?

A
  1. Which calls are immediately transferred to provider?
  2. Which may be returned later?
  3. Which may be handled by another member of office staff (clerical or clinical)
    Written protocols should define the scope of clinical staff’s authority to give medical advice (thus, importance of good working relationship with staff)
37
Q

What must be documented with telephone communications?

A
  1. Date and time of calls
  2. Patient’s name, name of caller (relationship to patient)
  3. Complaint (timing, sxs, tx tried)
  4. Advice given
  5. Follow-up plan
  6. Disposition
    - Caller should be asked to repeat advice and document that pt voiced understanding of advice
38
Q

What can failure to document lead to?

A

liability related to failure to diagnose, delay of treatment, improper treatment, failure to follow up, breach of confidentiality

39
Q

What if unable to reach patient by phone?

A
  1. Document every attempt to reach patient
  2. If leaving a message, be sure there is consent to leave voice message
  3. Avoid leaving clinical information unless patient has given consent
40
Q

What are the advantages to using email when communicating with patients?

A
  1. Convenient for patients (no staying on hold or waiting by the phone)
  2. Automatically creates an electronic documentation trail
41
Q

What are the disadvantages to using email when communicating with patients?

A
  1. Does not generate any revenue for the practice
  2. Confidentiality concerns - patients don’t want to use encrypted e-mail system (even encrypted systems have been hacked)
  3. Poorly written email is still discoverable in a legal case
  4. Provider concerns with bombardment by email - patient abuse
  5. Difficulty confirming the identity of the patient in an email request
  6. Easier with an email to bring up multiple complaints or problems
42
Q

Used to monitor parameters used in management of chronic medical conditions

A

Flow sheets (I.e. for diabetes, hyperlipidemia, and anticoagulation)

43
Q

Why would documenting nonadherence/noncompliance be important?

A

important from a medico-legal standpoint

44
Q

Remember, who do you really work for?

A

YOUR PATIENTS!

Medical Communications (5 decks)

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