CDEO - Chapter 2 Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

Download CDEO - Chapter 2 Exam Questions with 100% Correct Answers | Verified | Updated 2024 and more Exams Advanced Education in PDF only on Docsity! CDEO - Chapter 2 Exam Questions with 100% Correct Answers | Verified | Updated 2024 (HIPAA) - Correct Answer-Health Insurance Portability and Accountability Act of 1996 HIPAA was enacted on _________. - Correct Answer-August 21, 1996 HIPAA aka as ______ bill, was originally enacted to provide rights and protections for participants and beneficiaries of group health plans. Under this law, exclusions for preexisting conditions were limited, and discrimination against employees and dependents based on their health status were prohibited. - Correct Answer-Kennedy-Kassebaum HIPAA also established the Healthcare _____ and _____ Control Program, a far-reaching program in healthcare, including both public and private health plans to combat both - Correct Answer-Fraud, Abuse pg. 1 professoraxe l HIPAA _______ provisions required that sections of the law be publicized to explain the standards for the electronic exchange, privacy, and security of health information. - Correct Answer-Administrative Simplification Congress did not enact privacy legislation within the specified time governed by HIPAA. The U.S. Department of Health and Human Services (HHS) developed a proposed rule, which was released for comment on November 3, 1999. Many comments were received, and modifications were made to the rule. The modifications were published and released in final form on ______. - Correct Answer-August 14, 2002 _____ issued a privacy rule to set a national standard for the protection of certain health information. - Correct Answer- HHS The _______ standards address how an individual's protected health information (PHI) may be used. Its purpose is to protect individual - Correct Answer-Privacy Rule - Correct Answer-privacy, while promoting high-quality healthcare and public health and well-being. pg. 2 professoraxe l Healthcare ________ include billing services, repricing companies, and community health management information systems that process nonstandard information, received from another entity, into a standard (ie, standard format or data content) or vice versa. In most instances, healthcare clearinghouses receive individually identifiable information for processing services to a health plan or healthcare provider as a business associate. In these cases, only certain provisions are applicable to the clearinghouses' uses and disclosures of protected health information. - Correct Answer- clearinghouses _______ occur through electronic exchanges, which allow information to be transferred between two parties for specific purposes. - Correct Answer-Transactions A healthcare provider will send a claim to a health _____ to request payment for the medical services he or she provides. - Correct Answer-plan _____ regulations standardized transactions for Electronic Data Interchange (EDI) of healthcare data. These transactions are: claims and encounter information, payment and remittance advice, claims status, eligibility, enrollment and pg. 5 professoraxe l disenrollment, referrals and authorizations, coordination of benefits, and premium payment. - Correct Answer-HIPAA Under _______, electronic transactions must use the adopted standard and adhere to the content and format requirements of ASC X12N or NCPDP (used for certain pharmacy transactions) for each transaction. An additional rule was adopted to standardize the code sets for diagnoses and procedures. These code sets include: HCPCS (Healthcare Common Procedure Coding System—ancillary services and procedures); CPT® (Current Procedural Terminology— physician's procedures); CDT® (Current Dental Terminology— dental procedures); ICD-9 (International Classification of Diseases-9th revision— diagnosis and inpatient hospital procedures); ICD-10 (International Classification of Diseases- 10th Revision, which replaced ICD-9 on October 1, 2015); and NDC (National Drug Codes). - Correct Answer-HIPAA In addition to the standardization of the codes used to request payment for medical services, a _______ for employers and providers must be used on all transactions. - Correct Answer- unique identifier _______ perform certain functions or activities, which involve the use or disclosure of individually identifiable health pg. 6 professoraxe l information, on behalf of another person or organization, without being a member of the entity's workforce. These services include claims processing or administration, data analysis, utilization review, billing, benefit management, and re-pricing. - Correct Answer-Business associates _______ associate services to a covered entity are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services. - Correct Answer-Business To be considered a business associate, the persons or organizations would involve the use or disclosure of ________ between the two parties. - Correct Answer-protected health information A covered entity ____ be a business associate of another covered entity. - Correct Answer-can HITECH - Correct Answer-Health Information Technology for Economic and Clinical Health Act pg. 7 professoraxe l Not use or disclose __________ other than as permitted or required by the Agreement or as required by law - Correct Answer-protected health information Use appropriate ________, and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information, to prevent use or disclosure of protected health information other than as provided for by the Agreement - Correct Answer-safeguards ________ to covered entity any use or disclosure of protected health information not provided for by the Agreement of which it becomes aware, including breaches of unsecured protected health information as required at 45 CFR 164.410, and any security incident of which it becomes aware; - Correct Answer-report ensure that any _______ that create, receive, maintain, or transmit protected health information on behalf of the business associate agree to the same restrictions, conditions, and requirements that apply to the business associate with respect to such information; - Correct Answer-subcontractors pg. 10 professoraxe l Maintain and make available the information required to provide an _____ of disclosures to the [Choose either "covered entity" or "individual"] as necessary to satisfy covered entity's obligations under 45 CFR 164.528; - Correct Answer-accounting Business associate may ____ or _____ protected health information as required by law. - Correct Answer-use, disclose ________ agrees to make uses and disclosures and requests for protected health information [Option 1] consistent with covered entity's minimum necessary policies and procedures. [Option 2] subject to the following minimum necessary requirements: [Include specific minimum necessary provisions that are consistent with the covered entity's minimum necessary policies and procedures.] - Correct Answer-Business associate If a covered entity identifies a material breach or violation of the contract or agreement, _________ steps must be taken to cure the breach or end the violation. If not possible, the contract must be terminated, and the problem reported to the Department of __________ - Correct pg. 11 professoraxe l Answer-reasonable, health and human services office for civil rights The _______ includes exceptions to the business associate standard, which DO NOT REQUIRE a ______ entity to have a written agreement in place prior to disclosing protected health information. Examples include: ________ for treatment of the individual, such as: 1.) hospital referring a patient to a specialist and transmitting the patient's medical chart for treatment purposes 2.) A physician sending specimens to a lab for analysis 3.) A hospital lab sending specimens to a reference lab for analysis. Disclosures to a health plan ______, such as an employer, by a group health plan that provides the health insurance benefits or coverage for the group health plan. The collection and sharing of protected health information by a health _____ that is a public benefits program, such as Medicare. - Correct Answer-Privacy Rule, covered, healthcare provider, sponsor, plan pg. 12 professoraxe l providing his or her signature. Covered entities are expected to use their judgment in situations where the patient is incapacitated, or the covered entity is not available to provide the care that is in the best interest of the patient. 4. Incidental use and disclosure is permitted, as long asthe covered entity has reasonable safeguards in place to ensure that the informatio - Correct Answer-Permitted The minimum necessary standard is a key protection of __________ - Correct Answer-HIPAA Privacy Rule The _____ standard is a key protection of HIPAA Privacy Rule - Correct Answer-minimum necessary The ______ requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose. - Correct Answer-Privacy Rule A _______ is required to develop and implement policies and procedures to reasonable limit uses and disclosures to the minimum necessary - Correct Answer-covered entity pg. 15 professoraxe l When the minimum necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the ______ medical record for a particular purpose, unless it can specifically justify the record as the amount reasonably needed for that purposeTo strike a balance between the individual interest and public interest for specific protected health information - Correct Answer-entire The Privacy Rule permits use and disclosure of this information without an individual's authorization or permission through public interest and benefit activities. There are 12 national priority purposes: Required by law, Public health activities, Victims of abuse, neglect, or domestic violence, Health oversight activities, Judicial and administrative proceedings, Law enforcement purposes, Decedents (Funeral directors or medical examiners), Cadaveric organ, eye, or tissue donation, Research, Serious threat to health or safety, Essential government functions, Workers' compensation - Correct Answer-12 A ________ is protected health information from which certain specified direct identifiers have been removed. Limited data sets may be used for research, healthcare operations, and public health purposes, as long as there is an agreement with promised safeguards in place for the protected health information. - Correct Answer-limited data set pg. 16 professoraxe l A privacy practice notice must be provided by ______ covered entity and must contain certain elements to notify individuals as to how the covered entity will use and disclose the individual's protected health information. The notice must clearly explain the covered entity's obligation to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice. The covered entity must also inform the patient of his or her individual rights, and the steps to follow (including a point of contact for further information) if an individual feels his or her privacy rights have been violated. - Correct Answer-each Beginning April 14, 2003 HHS said a distribution of the ______ must be provided to individuals promptly when there is a direct treatment relationship with the individual and a covered healthcare provider. The rule indicates the notice must be provided Not later than the ____ service encounter by personal delivery of patient services, electronically or through mail; By posting the notice in a clear and prominent place that can be easily seen by people seeking services; and In emergent situations, the notice must be furnished when the emergency has abated. - Correct Answer-privacy notice, first pg. 17 professoraxe l workforce member who violates any area of the privacy rules. 4.) Covered entities are required to mitig - Correct Answer- administrative Fully insured group _______ have only two obligations: (1) banned from retaliatory acts and waiver of individual rights, and (2) to provide documentation for the disclosure of protected health information through documentation. HHS, Office of Civil Rights (OCR) is responsible for administering and enforcing the standards set forth in the Privacy Rule and may conduct complaint investigations and compliance reviews. - Correct Answer-health plans Covered entities failing to comply and cooperate with any investigation initiated by ____ may be subject to civil money penalties. The penalties will vary significantly, depending on factors ranging from the date of the violation, whether the covered entity knew or should have known of the failure to comply, or whether the failure was due to willful neglect. Penalties may not exceed a calendar year cap for multiple violations of the same requirement. - Correct Answer-OCR For violations occurring prior to 2/18/2009, the penalty amount is up to $___ per violation, with a calendar year cap of $_______. For violations occurring on or after 2/18/2009, the pg. 20 professoraxe l penalty amount ranges from $100 to $50,000 or more, per violation, with a calendar year cap of $1,500,000. - Correct Answer-100, 25,000 A covered entity will not receive a penalty if the failure to comply was not due to ____ neglect and was corrected within ___ days of identification that the error occurred; or, if the Department of Justice imposed a criminal penalty. Penalties can be reduced at the discretion of OCR if the failure to comply was due to reasonable cause, and the penalty would be excessive based on the nature and extent of the noncompliance. - Correct Answer-willful neglect, 30 The ______ is responsible for criminal prosecutions under the Privacy Rule. - Correct Answer-Department of Justice Criminal penalties are imposed when a person _______ obtains or discloses individually identifiable health information in a way that violates the Privacy Rule. The penalties begin at $50,000 and up to one- year imprisonment and increase to $100,000 and up to fiveyears imprisonment if the conduct involved false pretenses; or, as much as $250,000 and up to 10 years imprisonment if the conduct involves the intent to sell, transfer, or use identifiable health information pg. 21 professoraxe l for commercial advantage, personal gain, or malicious harm. - Correct Answer-knowingly ________ regulations adopted administrative, technical, and physical safeguards necessary to prevent unauthorized access to PHI. The standards, in effect for all covered entities since April 20, 2006, are designed to protect the confidentiality, integrity, and availability of ePHI a covered entity creates, receives, maintains, or transmits. The intent is to identify and protect against reasonably anticipated threats to the security or integrity of the information and protect against reasonably anticipated impermissible uses and disclosures. - Correct Answer-HIPAA security The Security Rule defines "________" to mean ePHI is not available or disclosed to unauthorized persons. - Correct Answer-confidentiality The ________ confidentiality requirements support the Privacy Rule's prohibitions against improper uses and disclosures of PHI. - Correct Answer-Security Rule's The Security Rule also promotes the ____ and _____ of ePHI. - Correct Answer-integrity, availability pg. 22 professoraxe l necessary," the Security Rule requires a covered entity to implement policies and procedures for authorizing access to ePHI only when such access is appropriate based - Correct Answer-Risk analysis 1.) Facility Access and Control: A covered entity must limit physical access to its facilities while ensuring authorized access is allowed. 2.) Workstation and Device Security: A covered entity must implement policies and procedures to specify proper use of and access to workstations and electronic media. A covered entity also must have in place policies and procedures regarding the transfer, removal, disposal, - Correct Answer-Physical Safeguards - Correct Answer-and re-use of electronic media, to ensure appropriate protection of ePHI. 1.) Access Control: A covered entity must implement technical policies and procedures that allow only authorized persons to access ePHI. 2.) Audit Controls: A covered entity must implement hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use ePHI. 3.) Integrity Controls: A covered entity must implement policies and procedures to ensure ePHI is not improperly altered or pg. 25 professoraxe l destroyed. Electronic measures must be put in place to confirm ePHI has not been improperly altered or destroyed. 4.) Transmission Security: A covered entity must implement technical security measures that guard against unauthorized access to ePHI being transmitted over an electronic network. - Correct Answer-Technical Safeguards ________ Requirements: These include business associate contracts or other arrangements where covered entities and business partners are required contractually to follow the organization's Security Rules. - Correct Answer-Organizational _______ Requirements: This requires covered entities to implement reasonable and appropriate policies and procedures to comply with the standards. - Correct Answer- Policies, Procedures, and Documentation A ______ is a repository for an individual's health information and is kept for planning patient care and providing ______ communication to all involved in providing patient care. The information may include information from a nurse, physician, dentist, chiropractor, psychiatrist, or other healthcare provider. - Correct Answer-medical record, written pg. 26 professoraxe l Details within the medical record may include information about medical history (____ test performed, ______ prescribed, information about ______, and/or details about ______, family medical history, etc.). - Correct Answer-labs, medications, operations, lifestyle _______ are required to maintain complete and accurate medical records for all services they perform. These requirements are generally enforced through licensing, the certification process, or credentialing with insurance carriers - Correct Answer-Healthcare providers All entries in the medical record must be _____. - Correct Answer-legible Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to _____ or other ______ patient events. - Correct Answer-medical errors, adverse All entries in the medical record must be ______. - Correct Answer-complete pg. 27 professoraxe l The requirements for dating and timing do not apply to orders or prescriptions that are generated outside of the hospital until they are _______ to the hospital at the time of service. - Correct Answer-presented Once the hospital begins processing such an order or prescription, it is responsible for ensuring that the implementation of the order or prescription by the hospital is promptly ____ and _____ in the patient's medical record - Correct Answer-dated, timed The record begins at _____ and chronicles _____, minor and major _____, _____ measures taken, and _____ progression. - Correct Answer-birth, diseases, illnesses, preventive, growth Components commonly found in all medical records make each as _____ as the individual to whom it belongs: information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard. - Correct Answer-unique All entries in the medical record must be dated, timed, and authenticated, in ____ or ____ form, by the person pg. 30 professoraxe l responsible for providing or evaluating the service provided. - Correct Answer-written, electronic The time and date of each entry (orders, reports, notes, etc.) must be accurately ______. - Correct Answer-documented ______ establishes when an order was given, when an activity happened or when an activity is to take place. - Correct Answer-Timing Timing and dating entries are necessary for patient _____ and ______. - Correct Answer-safety, quality of care Timing and dating of entries establish a ______ for future actions or assessments and established a timeline of events. Many patient interventions or assessments are based on time intervals or timelines of various signs, symptoms, or events. (71 FR 68687) - Correct Answer-baseline The _____ must have a method to establish the identity of the author of each entry. This would include verification of the author of faxed orders/entries or computer entries. - Correct Answer-hospital pg. 31 professoraxe l The hospital must have a method to require that each author takes a specific action to verify that the entry being authenticated is his orher entry or that he or she is respon- sible for the entry, and that the entry is ______ - Correct Answer-accurate Each medical record must have a personal identification ______ assigned to it, which is specific to every individual patient. This ensures accuracy of the details contained within the record and adds a layer of security to prevent unauthorized use. - Correct Answer-number A patient's medical _____ is required to be in the record so healthcare providers can make assessments about a past, current, or future state of an illness. By reviewing what has happened in the past with the patient, a healthcare provider can identify risk prevention for future illnesses. - Correct Answer-history The various types of history that are often involved in the medical record are: - Correct Answer-surgical, medications, allergies, family, social, immunization, developmental pg. 32 professoraxe l Because confusing abbreviations can create problems with patient care, the_____ has published a standard for the appropriate use of abbreviations as well as a minimum list of dangerous abbreviations, acronyms, and symbols. - Correct Answer-Joint Commission The "_____" list should be included on each provider's list U, u (unit) IU (International Unit) Mistaken for "0" (zero), the number "4" (four) or "cc" Mistaken for IV (intravenous) or the number 10 (ten) Write "unit" Write "International Unit" - Correct Answer-Do Not Use In the absence of one law that clearly defines the _____ requirements of the medical record, we must look to various sources to supply requirements that govern the content of medical records. These include statutory, regulatory, accrediting, institutional, and professional guidelines. When all the guidelines are reviewed together, an understanding of legal requirements governing medical records can be obtained. - Correct Answer-legal _____ provisions can be federal or state laws or municipal codes. Federal law establishes the Conditions of Participation (CoP) in federal reimbursement programs such as Medicare pg. 35 professoraxe l and requires all institutions to maintain clinical records on all patients. However, the law does not clearly define what must be a part of the medical record. States generally govern that a medical record must be created, and occasionally there is more specific guidance available to define what should be included within the medical record (such as medical histories, reports, prognoses, medications ordered, etc.). - Correct Answer-Statutory The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital(a) Standard: Organization and staffing. The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. (b) Standard: Form and retention of record. The hospital must maintain a medical record for each inpatient and outpatient. - Correct Answer-1, 2 _____ must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. (1) Medical records must be pg. 36 professoraxe l retained in their original or legally reproduced form for a period of at least 5 years. (2) The hospital must have a system of coding and indexing medical records. The system must allow for timely retrieval by diagnosis and procedure, to support medical care evaluation studies. (3) The hospital must have a procedure for ensuring the confi- dentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individ- uals cannot gain access to or alter patient records. - Correct Answer-Medical records Original medical records must be released by the _____ only in accordance with federal or state laws, court orders, or subpoenas. - Correct Answer-hospital ______ are closely related to statutory provisions but are delegated (by statutory provisions) to certain executive agencies to enforce rules and regulations related to the medical health record. The regulations on both the state and federal level vary between general statements that a medical record is maintained, broad listings of content requirements, and specific detailed provisions governing content. - Correct Answer-Regulations pg. 37 professoraxe l through _____ safety and hospital acquired ______. - Correct Answer-medication, infections To be ______ by HSS for Medicare and the JC, the following medical record requirements must be in place for all patients: Admission report, Consent to treatment form, Attestation statement, Medical history, Physician's orders, Report of physical examination, Progress notes, Pathology reports, Radiology reports, Consultation reports, Anesthesia record, Operative report, Nurse's notes, Vital signs graphics, Medication sheet, Laboratory report, Physical therapy evaluation, Respiratory therapy evaluation, Special reports (Obstetrics, nursery), Discharge reports - Correct Answer- accredited All records must be kept for all ____ and _____ for healthcare services. - Correct Answer-admissions, encounters Many of the accreditation standards come from Medicare's __________. For example, the list of what is included in a medical record partially comes from the Conditions of Participation for Hospitals. - Correct Answer-Conditions of Participation pg. 40 professoraxe l All medical record entries should be complete and legible and should include the legible identity of the ____ and the ______. - Correct Answer-provider, date of service Occasionally, a provider will need to ____ and _____ a medical record entry. - Correct Answer-amend, correct When a _____ is made to the medical record, the following record-keeping principles apply: 1. Clearly and permanently identify any amendments, corrections, or addenda. 2. Clearly indicate the date and author of any amend- ments, corrections, or addenda. 3. Clearly identify all original content (do not delete). - Correct Answer-modification When correcting a paper medical record, a ________ through should be used so the original content is still readable. - Correct Answer-single line strick The person altering the medical record must ___ and ____ the revision, amendment, or addenda. - Correct Answer-sign, date For electronic health records (EHR), the amendment, correction, or delayed entry must be _____ identified. There pg. 41 professoraxe l must also be a way to provide a reliable means to clearly identify the original content and the modified content. - Correct Answer-distinctly The _____ altering the record and the date of the revision, amendment, or addenda must also be documented. - Correct Answer-person HIPAA rules require records to be maintained for ____ years of the date of its creation, or the date from which it was last in effect (whichever is later). - Correct Answer-six While the HIPAA Privacy Rule does not include medical record retention requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the _____ of medical records and other ____ for whatever period such information is maintained by a covered entity, including through disposal. - Correct Answer- privacy, PHI CMS requires hospitals to retain all patient records for at least ____ years after the submission of their closed cost reports. - Correct Answer-five pg. 42 professoraxe l Medical record documentation can come in many forms, such as ___, ____, _____ or ____(s). - Correct Answer-dictated, electronic, handwritten, template Each form of documentation has its own ____ areas. - Correct Answer-risk _____ records are often illegible and abbreviated. In addition, some information may be left off the medical record to reduce the amount of time it takes to write the note. - Correct Answer-Handwritten _____ , whether it is a pathology report or an operative report, should be an efficient, thorough, and organized method for recording patient information. Physicians must take special precautions. Often, there is a delay between the patient visit and when the information is placed in the chart. It may take several days for the transcriptionist to transcribe the recorded information and return it to the physician, who then reviews - Correct Answer-Dictation - Correct Answer-it for accuracy, signs it, and places it in the patient's chart. Any corrections should be made before it becomes part of the record. During this time, it may be pg. 45 professoraxe l necessary for the physician to enter into the chart a written summary of the services rendered on that date. The summary must contain enough information about the patient encounter so that it could be used in place of the transcription in case of loss, misfiling, or inaccuracies. Each hospital medical record has a specific section in the chart for nurse's notes, physician notes, laboratory results, X-rays, orders, etc. According to Medicare guidelines, the physician must ____ dictated notes before they are placed in the patient's chart. - Correct Answer-sign A _____ alongside the note indicates the provider has read the transcription and approved the information. - Correct Answer- signature When providers use _____ for documentation, they might have check boxes to indicate whether an exam of a body area or organ system is normal. Assist in full and complete collection of information but also allow for customization to fit the patient and the condition. In this case, any findings that are abnormal must have elaboration as to what is abnormal. It is helpful if the provider has a key explaining checklist symbols. - Correct Answer-templates pg. 46 professoraxe l Although electronic health records have great benefits, including the timeliness of documentation, there are also inherent risks. EHRs often have _____ templates that might cause a provider to document more than is medically necessary for that visit. Templates have _____ used to reduce the amount of time it takes to document a visit. This is different from cloning which is copy and pasting from another record. - Correct Answer-built-in, macros ____ or ____ medical records can cause many records to look the same and because information to be recorded that did not apply to that visit - Correct Answer-Copying, cloning Only individuals specified in ____ and ____ policies may make entries in the medical record. - Correct Answer-hospital, medical staff All entries in the medical record must be ____ and ______, and a method established to identify the _______. - Correct Answer-dated, authenticated, author The identification may include ____, _____, _____, _____ - Correct Answer-written signatures, initials, computer key, code pg. 47 professoraxe l Many ____ are found in the medical records. - Correct Answer-forms When ______ a medical record, it is important to know which forms to expect to see and what they are used for. - Correct Answer-auditing _______ form—This form gathers information needed to identify the patient and process claims and typically includes the date, patient demographic information (age, date of birth, address, Social Security number), insurance and financial information, and an emergency contact. - Correct Answer- Patient registration _______—This is an authorization form signed by the patient that allows their insurance carrier to pay the provider directly. Without this, the payment will go to the beneficiary and the provider will be required to collect payment from the beneficiary. - Correct Answer-Assignment of benefits Confirmation of ________ —The privacy notice provides a clear explanation of the entity's privacy practices and how the individual protected health information will be used. This form is signed documentation from the patient that he or she pg. 50 professoraxe l received the entity's privacy notice. - Correct Answer-Receipt of Privacy Notice _______ —Patients allow the release of their medical records by signing this form. This often has a place to allow the patient to designate who the medical information can be released to. - Correct Answer-Release of Information _______ —This form is signed by the patient to verify that the patient understands procedures, outcomes, and options. The patient can withdraw this consent for a procedure at any time. An informed consent consists of the patient's diagnosis (if known), the nature and purpose of a proposed treatment/procedure, alternative treatments/procedures, the associated risks and benefits, and the risk and benefits of not receiving the treatment/ procedure. - Correct Answer- Informed consent _____ information is required to describe the patient encounter each time he or she presents for medical services. - Correct Answer-Specific _____ may review past records or speak with other healthcare professionals, gather specific information from the patient pg. 51 professoraxe l through a series of questions, and physically assess the patient. They summarize his or her findings and create a plan to treat the patient. Each encounter will generally contain: - Correct Answer-Clinicians The ____ is a description of why the patient is presenting for healthcare services. It can also be referred to as the reason for the patient visit. - Correct Answer-chief complaint The ____ is how the patient describes the symptoms he or she is experiencing, and which have prompted the patient to seek medical attention. - Correct Answer-history The _______ is performed by the healthcare provider through a series of assessments and observations, focused around the symptoms described by the patient. - Correct Answer-physical examination The healthcare provider makes a ______ (also known as a diagnosis) about the cause of the symptoms, which is the provider's assessment of the problem. - Correct Answer- determination pg. 52 professoraxe l _____—Return visit information or referral - Correct Answer-R Whichever format is used, it is imperative the _______ of an evaluation and management visit accurately reflects the work performed during the visit. - Correct Answer-documentation If a MINOR office procedure is performed during an evaluation and management service, the documentation for that procedure can be included in the notes for the ________ service. It is not necessary to have a separate operative report. - Correct Answer-evaluation and management An _____ is a note produced by a healthcare professional for procedures they provide. The report must be written or dictated immediately after the procedure was performed and must contain a detailed summary of the findings throughout the surgery, the procedure performed, any specimens removed, the pre- and postoperative diagnoses, and the names of the primary performing surgeon and any assistants. - Correct Answer-operative report An operative report is typically divided into _____ main sections that include the header, indications for surgery, the pg. 55 professoraxe l detail or body of the procedure, and the findings. - Correct Answer-four The ____ of an operative note is designed to identify: l Patient name l Date of surgery l Preoperative diagnosis l Postoperative diagnosis l The procedure performed l Primary surgeon l Assistant surgeon(s) l Anesthesia administered l Anesthesiologist - Correct Answer-header The ______ typically gives a brief history outlining the reasons for or medical necessity for the procedure. - Correct Answer- indication Specific details of the surgery are described in the ____ of the note. The details in this area will determine the CPT® code(s) used to convey the surgical services performed. This description usually begins with the documentation of healthcare staff taking a "time out" to verify they have the correct patient, and identification of the expected procedure to take place. After this verification has been made, the operative note will provide details of the entire surgery, beginning with prepping the patient and the approach, and continuing to explain any find- ings, removal of specimens for analysis, and/or intra-operative complicationsThe operative report will be finalized with the findings upon completion of pg. 56 professoraxe l the surgery. Estimated blood loss will be docu- mented here, as well as the status of the patient upon comple- tion of the surgery. - Correct Answer-body - Correct Answer-Reading and analyzing an operative report requires time and great attention to detail. Challenges arise when the report indi- cates a specific procedure as being performed in the header, but the details in the body of the note do not support that proce- dure, or indicate additional procedures not reported in the title. For this reason, it is very important to read the entire note slowly and carefully. Attempt to gain an understanding of the entire surgical case before taking more time to read the report thoroughly to analyze for proper code assignment. - Correct Answer-Remember that physicians write an operative note in a manner that would be easily understood and interpreted by their colleagues. If there are elements missing in an operative note, it does not necessarily indicate that something wasn't done. Instead, it may be that the physician believes the missing element would be inherently "built into" the note by another physician reading that note. When this situation occurs, it is very important to provide training to remind physicians that the note is the only way to represent what was done in the operating room, and that pg. 57 professoraxe l An _____ or ____ for the study must also be retained. - Correct Answer-order, request It is not necessary for the orders to be maintained in the patient file but must be maintained by the _____. - Correct Answer-facility A valid order must contain, at minimum, the patient's ____, the radiology ____ requested (including the number of views), the reason (diagnosis or symptom) for the test, and the name and signature of the treating physician. l Patient name l Referring physician l Date and time of study l Patient history l Reason for study l Diagnostic and procedural statement l Extent of exam (limited, complete) l Number and type of views taken (bilateral, left, right) l Contrast material used, as appropriate; including type, amount, and method of administration l Separate description of each study performed on the patient l Recommendations for follow-up exam or additional studies needed l Comparison of prior studies, as appropriate l Indication of any limitations in study, such as poor image quality or poor patient prep l Summary of conversations with other healthcare providers l Findings, results, impressions, conclusions l Signatur - Correct Answer- name, test pg. 60 professoraxe l As with any other report, if any information within the report is unclear or conflicting the documenting provider should be ______ for verification and correction, as necessary. - Correct Answer-queried It is important to understand the radiological _____ described in these types of reports. The number of views is not necessarily the same as digital images or films. In rare instances, it may be required to take two images to complete one "view" of the patient (anatomy and obesity are two examples). - Correct Answer-views ______ (AP)—front to back - Correct Answer-Anteroposterior ______ (DEC)—patient lying on side - Correct Answer- Decubitus _____ (OBL)—angled view - Correct Answer-Oblique ______ (PA)—back to front - Correct Answer-Posteroanterior ______ (RAO)—right-front angled view - Correct Answer-Right anterior oblique pg. 61 professoraxe l ______ (RPO)—right-rear angled view - Correct Answer-Right posterior oblique _______ (LAO)—left-front angled view - Correct Answer-Left anterior oblique _______ (LPO)—left-rear angled view - Correct Answer-Left posterior oblique _______ open mouth cervical spine view to identify joint space C1 - Correct Answer-Odontoid ______ —thoracic X-ray with one or both arms overhead - Correct Answer-Swimmers ______ —two views of a structure taken at different angles - Correct Answer-Stereo ______ —a view of the chest to include the apex of the lung - Correct Answer-Apical lordotic pg. 62 professoraxe l needs to document medical necessity in the patient's medical record, as well as an indication that he or she ordered the tests. - Correct Answer-circle, sign When the specimen is sent to an outside facility for testing, the lab _______ the test should bill the service. - Correct Answer-performing _____ hospital laboratories are reimbursed based on a fee schedule for Medicare. - Correct Answer-Outpatient - Correct Answer-The lab report should contain the following elements: l Patient name and identification number l Name of laboratory l Name of physician or practitioner ordering the test l Date and time of the collected specimen, and date and time of receipt l Reason for an unsatisfactory specimen, if applicable l Test or evaluation performed l Result l Date and time of report _______ includes physical therapy, occupational therapy, and speech-language pathology services.Outpatient therapy services are covered when: l services were required because the individual needed therapy services; and l a plan of care has been established and is periodically reviewed; and l pg. 65 professoraxe l services were furnished while under the care of a physician; and l the physician or nonphysician practitioner certifies the plan of care. - Correct Answer-Outpatient therapy Documentation requirements for _____ services include: l Evaluation and Plan of Care; l Certification and recertification; l Progress reports which provides justification for the medical necessity of treatment information; and l Treatment encounter notes for each treatment day and should include: £ Date of treatment £ Treatment, intervention, or activity £ Total timed treatment by individual modality and total treatment time in minutes (includes timed codes and untimed codes) £ Signature and professional identity of the qualified professional furnishing the treatment £ Additional information may include response to treatment or changes. - Correct Answer-therapy Therapy cannot start until the initial _____ is established. - Correct Answer-plan of care A plan of care should be established for each type of ____. The plan of care must contain: l Diagnoses; l Long term treatment goals; l Type of rehabilitation therapy services (physical therapy, occupational therapy, or speech-language pathology) identifies each specific intervention, procedure, or pg. 66 professoraxe l modality, to support billing and verify correct coding; l Amount of therapy—number of treatment sessions in a day; l Duration of therapy—number of weeks or number of treatment sessions; and l Frequency of therapy—number of treatment sessions in a week. l Current functional limitations indicating severity of limitation and discharge goal functional limitation and projected severity of limitation. - Correct Answer-therapy - Correct Answer-Additional optional, but recommended, elements for a plan of care include: l Short term goals; l Goals and duration for the current episode of care; l Specific treatment interventions, procedures, modalities, or techniques and the amount of each; l Beginning date for the plan. The person who established the care (physician, NPP, clinical nurse specialist, or physician assistant) must ____ the plan of care. - Correct Answer-sign If a physical therapist or speech-language pathologist establishes the plan, a physician, NPP, clinical nurse specialist, or physician assistant must sign the _______. - Correct Answer-certification pg. 67 professoraxe l