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Templates Flashcards

To know about different templates, recall commenting structure for such templates, DOS rule, etc.

1
Q

Acknowledge of Receipt of Privacy Practices

A

Notice of Privacy Practices

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2
Q

Advance Care Planning

A 
Declaration as to Medical or Surgical Treatment
DNR
Five Wishes
Living Will
My Choices, My Wishes
DPOA
POA
Birth Certificate
Body Donation Card
Cord Blood Recipient Application
Directives to Physicians, Family or Surrogates
Expired Patient Checklist 
Guardianship Letter 
My Choices, My Wishes-Patient Values and Goals for Healthcare
Obituary - Newspaper or Funeral Home
Organ Donation Form
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3
Q

Bone Density

A

DEXA-STRIC

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4
Q

Bone Scan

A

Bone Scan WB-STRIC

Bone Scan Torso-Methodist Hospital

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5
Q

Cardio Echo

A

TTE-Methodist Hospital
Echo-PH
TEE-Heart and Vascular Institute

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6
Q

Cardio EKG

A

EKG-Kerrville Cardio

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7
Q

Cardiology Procedure Report

A 
SPECT-Methodist
MPI-Cardio Center
EBCT Heart Scan-Fredricksburg Heart
Event Monitor Report-U of C
Heart and Coronary Calcium Scanning Report-PH
Cardiac Catheterization-Methodist
Cardiac Stent Placement-Kerrville Heart Center
Cardiopulmonary Procedure-Fredricksburg Heart
Cardioversion-Methodist
Echo-guided Pericardiocentesis-PH
Gated Cardiac-U of C
Holter Monitor Report-Mayo
Radionuclide Ventriculogram-Cleveland Clinic
Stress Myoview-Heart Health Center
Stress Test-Healthy Heart Institute
Telemetry-Methodist
Holter Monitor-Cardio Center
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8
Q

Controlled Substance Agreement

A

Controlled Substance Agreement-Oxycontin

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9
Q

CT Scan Reports

A 
CT Abd W Contrast-NCBH
CT CAP WO Contrast-STGO
CT Abd Pelv W Contrast-STRIC
CTA Chest WWO Contrast-Methodist Hospital
CT Neck, Soft Tissue WO Contrast-BMSI
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10
Q

Death Certificates

A

Death Certificate

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11
Q

Dietician Assessment

A

MGT Tool
Nutrition Assessments / Consults
Nutrition screen sheet

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12
Q

Disability Paperwork

A

Claim Update-MetLife
Fitness For Duty Certification-Cardiovascular Systems
Letter Requesting Information-Cigna
Short-Term Disability Claim Form-Initial Report of Disability-TeamCare
Claim Supplement-Roofers Local No 96 Welfare Fund
ADA Medical Questionnaire-Minco Products

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13
Q

Drug Assistance

Description of Document-Sender of Document

A

Approved Assistance-Xalatan-Alcon Pharmaceuticals
Pt Assistance Form-Skyrizi-Abbie Pharma
Pt Assistance Drug Refill Request-Rituxan-Oncology Today
Denied Pt assistance-Nutera Nutrition-NutraRX

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14
Q

Family Member Testing Results

Date of Collection

Family Member Genetics Report-Facility

A

Family Member Genetics Report-CGC Genetics

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15
Q

Financial Counseling

Description of Document

A 
Billing Information
Summary of Liability
Letter to Billing Dept
ABN
Angel Foundation
Co-Pay Assistance
Open Arms
Benefit Investigation Summary
MHCP Application/Renewal
Approval of NPAF Assistance
AOB
SPRL
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16
Q

FISH Results

Date of Collection

FISH-Specimen Source-Sender

A

FISH, Liver-Agendia
FISH, Pleural Fluid-NeoGenomics
FISH Analysis ALK Lung, Rt Lung-NeoGenomics
Addendum FISH Analysis ROS1, Rt Lung-NeoGenomics

17
Q

Flow Cytometry on Peripheral Blood

Date of Collection

Flow Cyto, PB-Sender

A

Flow Cyto, PB-GenPath

Flow Cyto, Leukemia/Phenotyping-Ameripath

18
Q

Genetic Documents

Date of Service or Date on Document

Description of Document-Sender

  • Family tree will not have a facility name.
  • For updated Pedigree/Family Tree: use the original date as the DOS
A

Genetic Counseling Consult-Kate Hibbs CGC
Pedigree Update
Pedigree
Genetic Counseling, Myriad MyRisk Results, Pedigree Chart

19
Q

Genetic Results

Date of Collection

Description of Test, Body Part-Company-Date of report (# of pages)
Include ““Prelim”” and ““Addendum”” if applicable

A

BRAC Analysis-Myriad
BCR-ABL, Peripheral Blood-GenOptix-01/20/92 (3)
MSI Results, Adrenal Gland-Foundation Medicine-11/18/20 (3)
Gene Profile, Blood-Circulogene-01/20/10 (21)
Genetic Findings, Lung-Foundation Medicine-05/01/05 (7)
PD-L1, Lung-Foundation Medicine-10/10/00 (15)
Gynecologic Cancer Genes-Ambry Genetics-03/08/06 (14)
KRAS Mutation Analysis, Colon-Neo Genomics-05/03/11 (9)

20
Q

HIPAA

Date of Signature or Date of Document

Description of Document

A

Authorization for Disclosing Medical Records
Family Member Access Form
Denied Entry into Medical Record
Patient Confidentiality Questionnaire

Templates (1 decks)

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