TAUC Pre-scribeU exam with complete solutions.

What should be consistently documented in the Procedures section for billing purposes? Prescription medication discussions Review of outside diagnostic results Discussions with external professionals Independent historians needed What is included in the prescription medication discussions? 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 Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:15 Full screen Brainpower Read More What is included in review of outside diagnostic results? 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? Document any conversations you have with external sources such as: -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? 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? 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? Choose the numbered choices from the bottom section (top 4) -Acute -Chronic -Incidental lesion/mass Bottoms 6 are additions to top 4 What should all fractures be referred to as? Clinical not possible and you must include an associated fracture dx Should you document any refused procedures in the procedure note? yes Can diagnosis modifiers be modified at a later time? Yes in the diagnosis