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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
Who cares about documentation (and its accuracy)?
Everyone!

-Pt
-Coding and Billing department
-Insurance
-Govt
-Attorneys
-The physician
Complete this sentence:

'If it wasn't documented, it...
...wasn't done."
Good documentation is...
-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
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
Notes/Documents are:
-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
What is the 'biggest' myth of documentation?
-Assuming
**Challenges of documenting medical care are:
-Time
-Energy
-Thinking and Writing/Speaking simultaneously
-Attention
-Consistency
-Adapting to Technology
**Bottom line on Electronic Health Records**
-Not all are the same
-May not perform functions equally well
-NOT error-proof
-Electronic Signature = Actual Signature
-YOUR unique care ~ Unique Note
SOAP =
Sub = History (Chief Complaint)
Obj = Exam(s)
Assessment = Dx
Plan = Treatment (OMT goes here)
OMT Documentation and Coding: (7 steps)
-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
A section of SOAP notes has specific characteristics for OMM exam results. They are...
'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)
Others things to consider during Osteopathic exam:
-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
Any procedure (OMT or other) MUST be supported by:
-Relavent history
-Objective findings/studies
-Appropriate diagnosis
-Medical Decision making
-Informed consent
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
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)
T/F

Treat all the somatic dysfunctions you diagnose.
FALSE!

Do NOT need to treat every somatic dysfunction that is diagnosed.
T/F

Code for what you write in the Objective.
FALSE

Code only for what you treated ~ Plan
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.
Litmus test =
Ask: What would my evaluation, treatment, and SOAP note look like without the Osteopathic component??
Definition =

Converting your evaluation, findings, and procedures into appropriate numerical codes is...
Coding
Definition:

Submission of codes to insurance companies for reimbersement is...
Billing
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.
These are 2 separate and distinct clinical activities, which are prevented from being bundled for reimbersement. They are...
Evaluation and Management (E&M) and Procedures
Billing for OMT requires... (6 steps)
-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?
'MFR' would be found under...

S, O, A, P
Plan
'T6 FRS left' would be found under...

S,O,A,P
Objective
'Elevated Right First Rib' would be found under...

S,O,A,P
Objective
'Somatic Dysfunction of the Head' would be found under...

S,O,A,P
Assessment
'Appendectomy in 1985' would be found under...

S,O,A,P
Subjective
'Acute cystitis' would be found under...

S,O,A,P
Assessment
'Somatic dysfunction of the Thumb' would be found under...

S,O,A,P
Assessment
Advantages of Electronic Health Records (7):
-Legibility
-Search
-Speed
-Safety
-Security
-Storage
-Customizable
Disadvantages of Electronic Health Records (6):
-HIPAA compliance
-Expense
-Reliance on Technology
-Keyboard skills
-'Copy/Paste' and 'Template' Functions (be wary)
-'Litmus test' = is note too good, similar, or generic?