Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
21 Cards in this Set
- Front
- Back
|
documentation = legal record
|
must follow state practices
|
|
|
key legal aspects
|
legible & in ink (pref. black)
must be dated w/ date written, pref. on encounter date incl time if interdisciplinary authenticated by PT or PTA & appropriate to their respective scopes of practice SPT must be authenticated by PT or PTA errors neatly crossed out, fixed & authenticate w/ initials, date, time draw straight line through any empty spaces abbreviations only those authorized by facility |
|
|
information to include in notes
|
pt activities (e.g. exercise)
therapist-performed interventions only info directly relevant to pt's condition, prog, intervention |
|
|
audit
|
detailed review & eval of selected clinical records by qualified pro's to evaluate quality of care
|
|
|
authentication
|
id of author of a medical record entry by that author
|
|
|
HIPAA privacy rule
|
designed to protect privacy of health care data & promote standardization & efficiency
|
|
|
informed consent
|
voluntary, legally documented agreement by pt to allow a procedure
|
|
|
malpractice
|
negligence or misconduct by a professional
recognized upon injury or damage to client |
|
|
medical necessity
|
services & items reasonable & needed for dx / treatment of illness / injury or to improve fx of malformed limb
|
|
|
NPP
|
notice of privacy practices
written document provided to pt explaining privacy policies WRT medical records pt must sign acknowledgement |
|
|
third-party payer
|
anyone other than the pt or provider involved in financing
|
|
|
HIPAA
|
protects all individually identifiable PHI in any format
therapist must obtain pt consent to access/use/disclose PHI charts should be secured, attended, face down during treatment |
|
|
documenting informed consent
|
APTA guidelines vague
WCPT treatment description, risk explanation, expected benefits, antic timeframes, antic costs, reasonable alternatives |
|
|
WCPT
|
World Confederation of Physical Therapy
|
|
|
components of documenting informed consent
|
document
- PT gave pt necessary info - pt understood info & consented |
|
|
3 common legal issues
|
malpractice
lawsuits fraudulent charges |
|
|
malpractice
|
usually involves accident during treatment
keep comprehensive & current medical records to minimize legal risk |
|
|
lawsuits
|
PT records may be used in a lawsuit involving the pt
workman's comp, auto accident, etc |
|
|
fraudulent charges
|
documentation must support that intervention matches billing
PT docs must exactly match CPT codes & justify medical necessity |
|
|
CPT codes
|
current procedural terminology
|
|
|
preventing audit or legal action
|
currency & compliancy WRT coding, billing, documentation, requirements around medical necessity & skilled therapy services
minimize errors set up controls to counter risks pre-audit self-exam hire experts through legal counsel develop compliance plans develop corrective action plans |
