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34 Cards in this Set
- Front
- Back
Why do we document?
Hint: RECAP |
R = Record things
E = Explain things (complicated cases) C = Coding (the diagnosis) A = Accuracy (signature, etc) P = Protection of the pt's information |
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Who cares about documentation (and its accuracy)?
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Everyone!
-Pt -Coding and Billing department -Insurance -Govt -Attorneys -The physician |
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Complete this sentence:
'If it wasn't documented, it... |
...wasn't done."
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Good documentation is...
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-Recording events ACCURATELY and SUFFICIENTLY
-Explaining things clearly and logically -Self-contained -Demonstrating ability to make medical decisions -Clarifies what, why, and how treatment was done -Future Plans |
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What are these examples of:
-Purposely inaccurate -Assume -Mocking -Inappropriate judgements -Stereotyping -Writing note while upset or overly tired -Altering or destroying note inappropriately -Unconventional -Idiosyncratic -Illegible notes -Copying from previous note -Signing off without reviewing |
NEVERS of documentation
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Notes/Documents are:
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-Legal documents
-Acknowledgement of your involvement with the patient's care -Holding yourself to a Standard Of Care -Creating something for someone ELSE to potentially read OR interpret |
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What is the 'biggest' myth of documentation?
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-Assuming
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**Challenges of documenting medical care are:
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-Time
-Energy -Thinking and Writing/Speaking simultaneously -Attention -Consistency -Adapting to Technology |
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**Bottom line on Electronic Health Records**
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-Not all are the same
-May not perform functions equally well -NOT error-proof -Electronic Signature = Actual Signature -YOUR unique care ~ Unique Note |
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SOAP =
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Sub = History (Chief Complaint)
Obj = Exam(s) Assessment = Dx Plan = Treatment (OMT goes here) |
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OMT Documentation and Coding: (7 steps)
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-Standard medical evaluation
-Osteopathic evaluation -Diagnose Somatic Dysfunction (of regions involved with CC) -Is OMT appropriate? -Informed Consent for OMT -Performance of ANY OMT -Correct Terms and Numerical Codes for OMT diagnosis and OMT procedures |
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A section of SOAP notes has specific characteristics for OMM exam results. They are...
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'Somatic Dysfunction' based on TART.
Specify associated regions (by stating body region terminology, should NOT restate what is written in the Obj) Should be reasonably linked to presenting complaints (CC) |
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Others things to consider during Osteopathic exam:
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-Evaluate according to Standard of Care
-Under Assessment, list allopathic diagnoses also -Consider other important/relevant causes (i.e. social history or risk factors) -Are there any other equally efficacious treatments? -Realize Somatic Dysfunction can be a cause, effect, or coincidental finding for CC |
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Any procedure (OMT or other) MUST be supported by:
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-Relavent history
-Objective findings/studies -Appropriate diagnosis -Medical Decision making -Informed consent |
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What does discussing the following represent:
-Indications/Contraindications -Benefits/Risks -Side Effects of Therapy -Patient's Right to Choose -Options (i.e. no OMT, OMT later, other treatments) -Patient understanding -Patient permission -Parent or Legal Guardian (if necessary) |
= INFORMED CONSENT
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P section of SOAP note
With OMT... |
-States OMT was performed
-States the type of technique -States the body regions treated -Patient Response to OMT (TART, patient comments, physician observations) -Positives or Negatives (side effects, positioning, techniques) |
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T/F
Treat all the somatic dysfunctions you diagnose. |
FALSE!
Do NOT need to treat every somatic dysfunction that is diagnosed. |
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T/F
Code for what you write in the Objective. |
FALSE
Code only for what you treated ~ Plan |
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T/F
It doesn't matter how many techniques you use for a signle region, how long you treat, or if you treated both sides. |
TRUE
Only paid per region(s) involved. 1-2; 3-4; 5-6; 7-8; 9-10 Note: if performed bilaterally = only counts as 1. |
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Litmus test =
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Ask: What would my evaluation, treatment, and SOAP note look like without the Osteopathic component??
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Definition =
Converting your evaluation, findings, and procedures into appropriate numerical codes is... |
Coding
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Definition:
Submission of codes to insurance companies for reimbersement is... |
Billing
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Definition:
Giving credit for taking the effort to perform the H&P and formulate a diagnosis and a treatment plan is... |
Evaluation and Management (E&M)
Note: OMM evaluation is billed under this, while the technique is billed under procedures. |
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These are 2 separate and distinct clinical activities, which are prevented from being bundled for reimbersement. They are...
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Evaluation and Management (E&M) and Procedures
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Billing for OMT requires... (6 steps)
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-Osteopathic exam
-Osteopathic diagnosis -Performance of OMT -Modifier for E&M code (prevents bundling) -Specific terms used ('Somatic dysfunction', accepted body regions, 'OMT') -Is it covererd by their insurance? |
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'MFR' would be found under...
S, O, A, P |
Plan
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'T6 FRS left' would be found under...
S,O,A,P |
Objective
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'Elevated Right First Rib' would be found under...
S,O,A,P |
Objective
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'Somatic Dysfunction of the Head' would be found under...
S,O,A,P |
Assessment
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'Appendectomy in 1985' would be found under...
S,O,A,P |
Subjective
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'Acute cystitis' would be found under...
S,O,A,P |
Assessment
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'Somatic dysfunction of the Thumb' would be found under...
S,O,A,P |
Assessment
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Advantages of Electronic Health Records (7):
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-Legibility
-Search -Speed -Safety -Security -Storage -Customizable |
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Disadvantages of Electronic Health Records (6):
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-HIPAA compliance
-Expense -Reliance on Technology -Keyboard skills -'Copy/Paste' and 'Template' Functions (be wary) -'Litmus test' = is note too good, similar, or generic? |