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HIPPA - 🧠 ANSWER ✔✔Health Insurance Portability and Accountability Act
of 1996 and the Healthcare Fraud and abuse control program. Far-reaching
program to combat fraud and abuse in healthcare including both public and
private health plans.
Individuals protected health information - 🧠 ANSWER ✔✔Demographic
data, name, address, birth date, and SS number.
,central focus of clinical documentation - 🧠 ANSWER ✔✔should be to
demonstrate the quality of care provided to the patient with detail and
accuracy to facilitate optimum patient care.
CDEO Focus - 🧠 ANSWER ✔✔Clinical documentation improvement is a
proactive measure. The CDS will develop and monitor policies and
procedures that affect the documentation process. CDI should begin at the
front end of all services and care. Prevention of documentation issues is
the key.
CDEO Review - 🧠 ANSWER ✔✔The CDEO will review the findings of the
auditor to determine what should be done to resolve documentation the
issues on a proactive basis to prevent documentation and compliance
risks.
Other request than Federal Healthplans - 🧠 ANSWER ✔✔For different
reasons other than reimbursement, requests for medical records come
from different sources, for a multitude of different reasons. A few of these,
other than Federal Health Care Plans, are patients who are becoming more
active in their care , attorneys seeking information for third party liability
claims or mal-practice claims, other providers involved in the patients' care,
employers for pre-employment applications and worker's compensation
,cases, private payers, recruiting offices for military applications, and the
social security administration for the patients' SSI applications.
The appropriateness of the services provided - 🧠 ANSWER ✔✔In addition
to facilitating high quality patient care, a properly documented medical
record verifies and documents precisely what services were actually
provided. Other than the site of service the medical record may be used to
validate:
Medical Record Validates - 🧠 ANSWER ✔✔In addition to facilitating high
quality patient care, a properly documented medical record verifies and
documents precisely what services were actually provided. The medical
record may be used to validate: (a) The site of the service; (b) The
appropriateness of the services provided; (c) The accuracy of the billing;
and (d) The identity of the caregiver.
Detailed, well documented notes - 🧠 ANSWER ✔✔The details in a well-
documented note are a provider's best defense in any legal situation. If the
record is deficient in details, there is no "evidence" to support a provider's
testimony.
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, During the encounter or as soon as possible - 🧠 ANSWER ✔✔To maintain
an accurate medical record, what is the recommended appropriate time for
provider documentation?
If it is documented in the patient's medical record - 🧠 ANSWER ✔✔Quality
assurance of patient care is only evident if:
CDI Programs intent - 🧠 ANSWER ✔✔CDI programs are intended to be
performed on a prospective basis to improve documentation deficiencies
prior to claim submission. The intent is to identify deficiencies and make the
appropriate corrections and prevent future deficiencies. CDI programs can
also include retrospective reviews.
It encourages physician participation. - 🧠 ANSWER ✔✔Why is it important
to involve physicians in Clinical Documentation Improvement (CDI)
programs?
Failure to include the instructions for post procedure care and potential
complications. - 🧠 ANSWER ✔✔Which of the following documentation
deficiencies has a negative impact on patient outcomes?