EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
What should be consistently documented in the Procedures section for billing purposes?
Correct-Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? Correct-Document ll
discussions regarding any prescription medicine that the patient is already taking whenever it
is relevant to the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results? Correct-Whenever a patient
shows you outside labs or radiology results and asks you questions about them... Document:
outside lab results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you include?
Correct-Document any conversations you have with external sources such as:
, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? Correct-When a pt is
unable to provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do? Correct-Do not select any of the
three choices in the top under "uses for coding"
-uncomplicated
-systemic symptoms
-poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier? Correct-Choose the numbered
choices from the bottom section (top 4)
-Acute
-Chronic
, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? Correct-Clinical not possible and you must
include an associated fracture dx
Should you document any refused procedures in the procedure note? Correct-yes
Can diagnosis modifiers be modified at a later time? Correct-Yes in the diagnosis screen by
clicking on "dx mod" button
Are charts coded by providers? Correct-No
What do you do if the common diagnosis list does not contain the diagnosis you need?
Correct-You can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
-Select a second more accurate diagnosis on the second screen
, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
After you select the diagnosis, what must you specify in the next screen? Correct-
Laterality, visit number, further specification of anatomy
What can you do if you are unable to locate the exact diagnosis? Correct-Rename the
diagnosis by typing in the rename bar
A plan is not created for every diagnosis... T/F Correct-FALSE
What does a plan contain? Correct-Advice
Referral options
Discharge instructions
RX
Every plan should include how many items/topics that are chosen under the advice?
Correct-3
COMBINED TOGETHER)
What should be consistently documented in the Procedures section for billing purposes?
Correct-Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? Correct-Document ll
discussions regarding any prescription medicine that the patient is already taking whenever it
is relevant to the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results? Correct-Whenever a patient
shows you outside labs or radiology results and asks you questions about them... Document:
outside lab results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you include?
Correct-Document any conversations you have with external sources such as:
, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? Correct-When a pt is
unable to provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do? Correct-Do not select any of the
three choices in the top under "uses for coding"
-uncomplicated
-systemic symptoms
-poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier? Correct-Choose the numbered
choices from the bottom section (top 4)
-Acute
-Chronic
, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? Correct-Clinical not possible and you must
include an associated fracture dx
Should you document any refused procedures in the procedure note? Correct-yes
Can diagnosis modifiers be modified at a later time? Correct-Yes in the diagnosis screen by
clicking on "dx mod" button
Are charts coded by providers? Correct-No
What do you do if the common diagnosis list does not contain the diagnosis you need?
Correct-You can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
-Select a second more accurate diagnosis on the second screen
, EXAM:TAUC PRE-SCRIBE U( 6-DIFFERENT SETS
COMBINED TOGETHER)
After you select the diagnosis, what must you specify in the next screen? Correct-
Laterality, visit number, further specification of anatomy
What can you do if you are unable to locate the exact diagnosis? Correct-Rename the
diagnosis by typing in the rename bar
A plan is not created for every diagnosis... T/F Correct-FALSE
What does a plan contain? Correct-Advice
Referral options
Discharge instructions
RX
Every plan should include how many items/topics that are chosen under the advice?
Correct-3
