What is a reason a physician documentation can be difficult to review?
Illegible handwriting
The best scientific data available for clinical documentation is also known as
Evidence-based medicine
The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is de...
the best scientific data available for clinical do
the two part theory for high quality clinical docu
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What is a reason a physician documentation can be difficult to review?
Illegible handwriting
The best scientific data available for clinical documentation is also
known as
Evidence-based medicine
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The two-part theory for high-quality clinical documentation is a
cause-and-effect theory that is derived from which two sources?
Legal/Regulatory Sources and Peer-Reviewed Research
When discussing completeness in a health record, the physician has
fully addressed all concerns, as well as what other authentication?
Signature and date
Peer-reviewed academic literature states that this factor shows a
relationship to quality of care as well as support for concurrent CDI
programs:
Documentation
What evidence supports the lack of high-quality clinical
documentation in the medical field?
CDI is not taught in medical school
Which item is not recommended by the HHS and the OIG for minimum
compliance with clinical documentation regulations?
Physicians should include vaccination records
What does "reliable" in high-quality clinical documentation mean?
Physician documentation supports medical treatment
, Which item is an important aspect of consistent high-quality clinical
documentation?
Creates a clear picture for subsequent reviewers of documentation
Which aspect of the discharge summary is the biggest challenge to
house staff, mid-level practitioners, and attending physicians as
they compose the patient's discharge summary?
Timeliness
Which aspect of the patient's health record can a member of the house
staff or midlevel practitioner create, yet ultimately needs the
attending physician to confirm accuracy?
Problem list
Interns, residents, and fellows are physicians with lesser
accountability due to their inability to act as an attending
physician and are also known as ______.
House staff
Which two medical professionals serve as mid-level practitioners by
supporting physicians in the delivery of care?
Nurse practitioners and physician assistants
In 1982, which aspect of medical billing/reimbursement increased the
demand for accuracy and timeliness with regard to medical coding?
Reimbursement was driven by codes assigned to patient care
Which hands-on provider's documentation should the coder not use for
final coding?
Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient
at picking up deficiencies in clinical documentation yet must focus
on giving care?
Nurses
Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely clinical
documentation?
Outpatient
Which item is not an inpatient healthcare setting?
Emergency department
High-quality clinical documentation is the basis for what standard?
Gold standard
What allows the diagnostic, treatment, and response of information of
the patient to be aggregated into a uniform data set?
Coding
What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis?
Impression and plan
What description is an aspect of the coding professionals' job?
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