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Documenting encounters with providers:
- Patients Name
- Encounter date and reason
- Appropriate history and physical examination
- Review of all tests that were ordered
- Plan of Care, or notes on procedures or treatments that were given
- Instructions or recommendations that were given to the patient
- Signature of the provider who saw the patient
Patient's medical record must contain
- ~ Biographical and personal information, including the patients full name, social security number, date of birth, full address, marital status, home and work telephone numbers, and employer information as applicable
- ~ Copies of all communications with patient, including letters, telephone calls, faxes,, and e-mails; the patients' responses; and a note of the time, date, topic, and physician's response to each communication.
- ~ Copies of prescriptions and instructions given to the patients, including refills
- ~ Original documents that the patient has signed, such as authorization to release information and an advance directive
- ~ Medical allergies and reactions, or their absence
- ~ Up-to-date immunization record and history if appropriate, such as for a child
- ~ Previous and current diagnoses, test results, health risks, and progress
- ~ copies of referral or consultation letters
- ~ Records of any missed or canceled appointments
- ~ Requests for information about the patient (from a health plan or an attorney), and detailed log of whom information was released
the most common format is called a problem-oriented medical record
(POMR), includes general section with data from initial patient examination and assessment. Subsequent visits, the reason for those encounters are listed separately and have their own notes. SOAP notes are contained in problem-oriented medical records.
SOAP stands for: Subjective, Objective, Assessment, Plan
- ~ Subjective information is what the patient names as the problems or complaints
- ~ Objective information is what the physician finds during the exam of the patients; it may include data from laboratory tests and other procedures.
- ~Assessment, also called impression or conclusion, is the physician's diagnosis
- ~ Plan, also called advice or recommendations, is the course of treatment for the patient, such as surgery, medications, or other tests, including necessary patient monitoring, follow-up, and instructions to the patient.
Evaluation and management (E/M)
- when a provider evaluates a patient's condition and decides on a course of treatment to manage it.
- Usually documented with chart notes
- ~History and physical examination, a complete history and physical is documented with four types of information
- ~ the chief complaint
- ~ the history and physical examination
- ~ the diagnosis
- ~ the treatment plan
- Progress reports include:
- ~ comparisons of objective data with the patient's statements
- ~ goals and progress toward goals
- ~ the patient's current condition and prognosis
- ~ type of treatment still needed and for how long
- prepared during patient's final visit for a particular treatment plan or hospitalization, which includes:
- ~ the final diagnosis
- ~ comparisons of objective data with the patient's statements
- ~ whether goals were achieved
- ~ reason for and date of discharge
- ~ the patient's current condition, status, and final prognosis
- ~ instructions given to the patient at discharge, noting any special needs such as restrictions on activities and medications
Procedural services documentation
- ~ procedure or operative reports for simple or complex surgery
- ~ laboratory reports for laboratory tests
- ~ radiology reports for the results of X-rays
- ~ forms for specific purpose, such as immunization records, pre-employment physicals, and disability reports
Termination of the Provider- Patient relationship
must be documented by the physician. Provider must maintain patient's medical records according to the provisions of federal and state law. Provider must also send a letter to the patient that documents the situation and provides for continuity of care with the next provider. A copy of the termination letter must be placed in the patient's medical record.
Electronic health records
- provide patients' and providers' with immediate access to health information. Which saves times when vital patient information is needed.
- Computerized physician order management, physicians can enter orders for prescriptions, tests, and other services at any time.
- Clinical decision support, can provide latest medical research on approved medical websites to help with medical decision making
- Automated alerts and reminder, provides medical alerts and reminders for office staff to ensure that patients are scheduled for regular screening and other preventive practices. Also alerts can identify patient safety issues such as possible drug reactions.
Centers for medicare and medicaid services
- main federal agency responsible for health care. Also known as CMS
- Also ensures quality of healthcare:
- ~regulating all laboratory testing other than research performed on humans
- ~preventing discrimination based on health status for people buying health insurance
- ~researching the effectiveness of various methods of health care management, treatment, and financing
- ~evaluating the quality of health care facilities and services
Number/ Official Name
- X12 837------ Health care claims or equivalent encounter information/coordination of benefits
- X12 276/277----- Health care claim status inquiry/response
- X12 270/271----- Eligibility for a health plan inquiry/response
- X12 278----- Referral certification and authorization
- X12 835----- Health care payment and remittance advice
- X12 820----- Health plan premium payments
- X12 834----- Health plan enrollment and disenrollment
HIPAA National Identifiers
- Are for:
- ~Health care providers
- ~Health plans
are numbers of predetermined length and structure, such as a person's social security number. They are important because unique numbers can be used in electronic transactions.
EIN- Employer Identification Number
The employer identifier is used when employers enroll or disenroll employees in a health plan (x12 834) or make premium payments to plans on behalf of their employees (x12 820). The employer indentification number issued by the Internal Revenue Service is the HIPAA standard
National Provider Identifier (NPI)
Is the standard for the identification of providers when filing claims and other transactions. The NPI has 9 numbers and a check digit for a total of 10 numbers. These numbers are assigned by federal government to individual providers, such as pharmacies and nurses, and also provider organizations such as hospitals, pharmacies, and clinics. CMS maintains the NPIs as they are assigned in the NPPES (National Plan and Provider Enumerator System), a database of all assigned numbers, NPI cannot be changed once it is assigned, regardless of job or location changes.