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MIBC F3
A Fordney Ch3
| Question | Answer |
|---|---|
| A medical record is considered | medical information and a health record |
| A medical report is a | permanent legal document and a part of the medical record |
| The key to substantiating procedure and diagnostic code selections for proper reimbursement is | supporting documentation in the medical record |
| The chronologic recording of pertinent facts and observations about the patient's health is known as | documentation |
| Reasons for documentation are | defense of a lawsuit and/or insurance carriers require accurate documentation that supports procedure and diagnostic codes |
| The SOAP in patient medical record charting may be defined as | S-subjective, O-objective, A-assessment, P-plan |
| When a patient fails to return for needed treatment, documentation should be made | In the patient's medical record, the appointmant book and on the financial record or ledger card |
| How should an entry in a patient's medical record be corrected | cross out the incorrect entry, substitute the correct information, date and initial the entry |
| A concise statement describing the symptom, problem, condition, dx, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as | CC |
| Levels of evaluation and management services are based on type(s) of physical examination that may be | problem focused |
| An expanded problem-focused examination is a/an | limited examination of the affected body area |
| Official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the" | final diagnosis, operative notes, discharge summaries |
| Varicella is the medical term for | chickenpox |
| Dyspnea is the medical term for | difficult breathing |
| Coryza is the medical term for | a cold |
| Alopecia is the medical term for | baldness |
| A diseased condition or state is known as | morbidity |
| Underlying disease or other conditions present at the time of the visit is known as | comorbidity |
| What does comorbidity mean | underlying diseases or other conditions present at the time of the visit |
| A new patient is one who | has not received any professional services from a physician who belongs to a group practice within the past 3 years |
| An established patient is one who | has previously received professional services from a physician or another physician of the same specialty who belongs the the group within the past 3 yrs |
| In dealing with managed care plans, a referral is | the transfer of the total or specific care of a patient from one physician to another or the term used when requesting an authorization for the patient to receive services elsewhere |
| When a discussion takes place with a patient concerning the risks and benefits of treatment options it is considered | counseling |
| Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the | right lower quadrant |
| Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as | intermediate |
| The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading | Simple |
| A review of patient records done before billing is submitted is called | prospective |
| Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime | exclusion from program participation is mandatory |
| Who may sign for disclosure of the medical record of a minor patient who is legally capable of consenting to medical treatment | Only the minor patient |
| Which of the following cases should NOT use fax transmission | Transmission of documents relating to information on sexually transmitted diseases. Any routine transmission of patient information. Transmission of documents relating to alcohol treatment |
| Who may accept a subpoena | The prospective witness, or an authorized person |
| Preservation of medical records is governed by | state and local law |
| Records that must be retained indefinitely include | patients' medical records, x-ray films, and inactive patients' medical records |
| Provider who sends the patient for tests or treatment | referring physician |
| Provider whose opinion is requested by another physician about evaluation and management of a specific problem | consulting physician |
| Provider who is the medical staff member who is legally responsible for the care and treatment given to a patient | attending physician |
| Individual who directs the selection, preparation, or administration of tests, medications, or treatment | ordering physician |
| Provider who renders a service to a patient | treating or performing physician |
| Situation associated with the pain/symptom | context |
| Area of the body in which the symptom is occuring | location |
| When the pain/symptom occurs | timing |
| Character of the symptom/pain (burning, gnawing) | quality |
| How long the symptom/pain has been present and how long it lasts when the patient has it | duration |
| Symptom/pain and other changes that are noted when the symptom/pain occurs | associated signs and symptoms |
| Things done to make the symptom/pain worse or better | modifying factors |
| Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness | consultation |
| Transfer of the total care of a patient from one physician to another | referral |
| Providing similar services to the same patient by more than one physician on the same day | concurrent care |
| Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition | continuity of care |
| Discussion with a patient, family, or both about diagnostic results and instructions for treatment | counseling |
| Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician | critical care |
| Care provided during a life-threatening condition in the hospital emergency department | emergency |
| Degree of symptom and/or pain on a scale from 1 to 10 | severity |
Created by:
leemiller
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