Week 4 Documentation/PTA

Question 1

What are 6 main purposes of documentation?

Answer 1

1. quality of care
2. justification of payment
3. research education
4. marketing
5. legal record
6. treatment guide

Question 2

What is quality of care internally?

Answer 2

review of procedures, assessment of patient satisfaction, staff accountability

Question 3

What are external companies who look at documentation?

Answer 3

JCAHO, OSHA, dept of public health

Question 4

How does documentation affect marketing?

Answer 4

what are most common diagnoses, primary referral sources, average LOS, most common used codes

Question 5

Who reviews documentation?

Answer 5

PT, PTA, RN,physicians, OT ,SLP

Question 6

When are documents reviewed?

Answer 6

Insurance authorization post examination for outpatient and SNF, throughout carefor MVA and worker’s compensation

Retrospective by private insurance (outpt and medicare- especially hospital admissions)

Question 7

How long do facilities in most states hold onto records?

Answer 7

7 years

Question 8

If you make a mistake how can you change documentation?

Answer 8

black ink only, initial it and single line through it

Question 9

What is an EMR?

Answer 9

pt file at a specific facility

Question 10

What is an PHR?

Answer 10

personal health record managed by pt

Question 11

What is an EHR?

Answer 11

electronic health record, ability to share med record across multiple facilities