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Flashcards in midterm Deck (32)
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1
Q

________ serves the dual purpose of providing a brief, short summary of the patient’s illnesses and acts as a tool for organizing the routine of documentation

A

problem list

2
Q

The Problem oriented medical record (POMR) has four parts:

A
  • Database
  • problem list
    initial plan
  • progress notes
3
Q

The first step in establishment of a problem oriented record is what

A

Database

4
Q

the oriented health record database should include _____ as expressed by the patient

A

chief complaint

5
Q

What should be all included in the database

A
Patient profile includes
a history of the present illness
past medical history
family medical history
a systems review and
results of a physical examination
6
Q

Once the database has been collected, an assessment of the information is made and a _________ is developed

A

problem list

7
Q

T/F

the problem list is kept in the back of the record within the SPOAP note

A

False —– front

8
Q

The function of a problem list is to

A

register all problems
maintain efficiency, thoroughness, and reliability in treating the “whole” patient
communicate with peers, patients, other health professionals and with oneself
indicate the status of problems, whether active, inactive or resolved
serve as a guide for patient care

9
Q

The development of the initial plan for the management of a patient’s problems, as defined in the problem list, is the ___step in planning patient care using a problem oriented health record

A

third

10
Q

What is the fourth step in the POMR formation

A

Progress notes

11
Q

what does SOAP note stand for

A

subjective
objective
Assessment
plan

12
Q

the process note must be problem – oriented and _____

A

functional

13
Q

what does SNOCAMP stand for

A
subjective 
nature of the presenting problem 
counseling and coordination of care 
medical decision making 
plan
14
Q

the final step in completing any medical record is the preparation of a ________

A

discharge summary

15
Q

Forms are used

A

Forms are used to collect, record, transmit, store and retrieve data
That is, they request action, record the outcome of the action, instruct and assist with the evaluation of data
Forms may also be designed to accompany legislation

16
Q

The medicolwegal aspect states that as a legal document, the health record should sufficient information to:

A
  • identify the patient
  • support DX
  • justify tx
  • accurately document results
17
Q

confidentiality must be maintained unless:

A
  • release is authorized by patient

- compelled by law ( subpoena, worker’s comp)

18
Q

What is the average length of retention for medical health records

A

most states5- 15 years

GA is 10

19
Q

If a request is made for the release of information, the HIPAA compliant authorization should contain the following:

A

Patient identification information (name, address, DOB, social security number)
Name of person/persons or institution to receive information
Name of person/persons or institution to make the disclosure
A clear description of the information to be used/disclosed & related dates.
Statement informing the patient of his right to revoke the authorization, how to revoke it, and any exceptions.

20
Q

If a request is made for the release of information, the HIPAA compliant authorization should contain the following

A

Statement that the information disclosed may be subject to re-disclosure by the recipient & no longer covered by the HIPAA Privacy Act.

Statement that the authorization will expire 1) on a certain date, 2) after a specific amount of time, or 3) upon the occurrence of some event related to the patient.

Date and signature of the individual authorizing the release
or
Date and signature of the individual’s authorized representative

21
Q

what does NCQA stand for

A

national committee for Quality Assurance

22
Q

what are important things to keep in mind when writing a documentation

A

make sure it has
brevity
clarity
accuracy

23
Q

Past Medical History or PMH should include the following for the initial note :

A
  • presented in outline form
  • include all medical problems (active or inactive) that weren’t responsible for the hospitalization or clinic visit
  • outline the problems from the most recent to the most remote
  • dx (historical) belong here in PMH ( symptoms belong in the review of systems (ROS)
    -ask for past/ of same or similar problems
  • under current care of any other healthcare provider
    -medications
    -past surgeries
  • ## trauma
24
Q

Family History should be presented as:

A
  • outline form
  • causes of death os family members
  • list major illness of family members ( if initial or annual exam have 3 generations of family member documented)
25
Q

Social history should be documented as:

A
  • narrative form
  • upbringing/education
  • cultural/ ethnic background
  • current life situation
  • living situation
  • relationships
    diet and sleep pattens
26
Q

For Occupational history try to identify what

A

if there is a relationship between the current complaint and occupation

27
Q

Review of Systems should be presented as:

A

presented in outline form
ROS appropriate to CC and for ruling out differentials
remember that diagnoses belong in the PMH and symptoms belong here in the ROS
if the patient relates any positive responses in the ROS you must explore the details
discuss all systems not already discussed in the HPI
pertinent positive and negative symptoms dealing with the present illness belong in the HPI, not the ROS

28
Q

When correcting errors it is recommended to use the ___ method

A
SLIDE 
SL-single line 
I- initials 
D- date 
E- entry
29
Q

the five components of HIPPA

A
  1. Electronic Transaction and Code Sets
  2. Privacy
  3. Security
  4. Enforcement
  5. National Provider Identi er (NPI)
30
Q

who is HIPPA affected by?

A
  1. providers
  2. health plans
  3. health clearing houses
  4. business parters
31
Q

what are the conditions that you must follow in order not to be HIPPA covered

A

-Keep records in your o ce on paper. Information in computers must only be out- put to paper and then mailed. No “Protected Health Information” (PHI) may be transmitted electronically to or from your o ce.
■ Do not use a billing service, clearinghouse or other third party to conduct electronic transactions such as submitting electronic claims for you.
■ Do not become a HIPAA Entity by function, contract, agreement, or certi cation.
■ Have no contracts or business agreements that require HIPAA compliance. Many health plans are now including a requirement for electronic claim submission in their agreements. Read your contract renewals carefully.
■ Do not use any internet applications, direct data entry, or point of service application containing PHI from your computer.
■ Do not fax PHI transactions from your computer (conventional, free-standing fax machines may be used).
■ Your practice is not located in a state that requires all claims to be be electronically submitted.

32
Q

what the 5 components for to HIPPA covered

A
  1. electronic transaction
  2. privacy
  3. security
  4. enforcement
  5. national identifier