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Which of the following b. Failure to include the instructions for post procedure
documentation care and potential complications.
deficiencies has a Although all the choices are deficiencies in capturing
negative impact on patient information, failure to inform a patient of
patient outcomes? potential post-operative complications could impact the
a. Failure to indicate the patient's recovery. In this question, you are determining
date of the patient's the option that affects clinical care of the patient.
last blood test.
b. Failure to include the
instructions for post
procedure care and
potential
complications.
c. Failure to sign the
patient's medical records
provided by another
physician.
d. Failure to report the
patient's pharmacy
preference for insurance
participation.
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What is an effective method d. Provide examples of the provider's documentation
for deficiencies with suggestions for improvement.
communicating Effective provider education regarding documentation
deficiencies is to provide
documentation deficiencies
examples of the physician's documentation deficiency
to a provider?
and feedback and tips on how to correct the
a. Provide documentation
deficiency.
tips for the most common
chronic conditions
treated.
b. Provide the
documentation deficiency
report quarterly.
c. Provide a report to the
medical director that
includes the findings for
all the
providers in the practice.
d. Provide examples of
the provider's
documentation
deficiencies with
suggestions for
improvement.
Which of the following is/are I, II, and IV
considered a purpose of It is appropriate to work towards proper reimbursement
documentation but the goal of CDI should never be increasing or
improvement programs? lowering revenue.
I. Improve patient outcomes.
II. Prepare physicians to
provide
documentation that supports
quality measures.
III. Promote coding lower level
services.
IV. Improve the provider query
process.
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How can an effective c. Provide a detailed record of the care provided to the patient.
CDI program improve The main goal for detailed medical records is to
patient outcomes? promote the continuity of care for the patient. This
a. Maximize the reimbursement allows providers to communicate
received.
b. Prohibit claim processing
errors.
c. Provide a detailed
record of the care
provided to the patient.
d. Allow providers to
support higher levels of
E/M services.
Which of the following a. Significant changes should be documented at each encounter.
recommendations Problem lists should be updated when a significant
should be made to providers change takes place to make sure the information on the
regarding the patient's problem list is still current and accurate. A common
problem list? problem is the list is created but it is not maintained so
a. Significant changes it becomes difficult to know which conditions are
should be current and which are resolved. If the problem list is
documented at each maintained, it is an effective tool for managing the
encounter. patient's conditions.
b. Problem lists consists of all
past medical
complications.
c. Problem lists should only
be used if the patient has
at least on chronic illness.
d. Significant changes
should be
documented once a
year.
Failure to document which a. Allergies: PCN
of the following statements Failure to document an allergy could lead to an allergic
could lead to a negative reaction if the provider prescribes a medication not
patient outcome? realizing the patient is allergic.
a. Allergies: PCN
b. Patient denies loss of
appetite or vomiting.
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c. Patient has remained on her
diet.
d. Patient indicates her
daughter lives with her to
assist in her care.
What is a documentation b. Documentation deficiencies may not be identified until after
challenge for services the provider has left.
Maintaining consistent and quality documentation can be difficult
provided by providers in an
in the inpatient
inpatient facility?
setting because deficiencies may not be identified until
a. Documentation may not
include the after the provider has left the facility.
progress note for a
subsequent inpatient
encounter.
b. Documentation
deficiencies may not be
identified until after the
provider has left.
c. Providers may not have
access to the entire
record for the inpatient
stay.
d. Providers may not have
access to the hospital EHR
to document the inpatient
encounters.
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