Documentation Review Questions

Identify the important roles provided by documentation in the medical record.

1. Facilitate the delivery of the best care possible
2. Communication and coordination of care to the entire health care team
3. Legal Record/Avoid Malpractice
4. Insurance/Medicare/Medicaid Reimbursement


Electronic Medical Record - digital versions of paper charts used in clinician offices, clinic and hospitals from that office


Electronic Health Record - broader view of patient care that contains information from all the clinicians involved in a patients care that is shared between health care providers


Personal Health Record - electronic health record maintained and managed by the patient

Medical negligence

Failure to exercise the care that a responsible health care professional would provide and caused harm but had no INTENTION of providing poor care

medical malpractice

a doctor or health professional made a mistake (medical negligence) but it was INTENTIONALLY reckless and individual was harmed

What factors need to be in place for a patient to have a case of medical malpractice?


How long do you have to file malpractice/negligence claim?

2 years (NE)

Why is it important to document non-compliance?

often forgot - proof that everything was covered but patient refused so that can't go back and say they didn't know ???

What insurance wants to see documented

-site of service
-medical necessity and appropriateness of diagnoses/treatment
-services accurately reported
-CPT and ICD-10-CM codes reported are supported

Guidlines for documentation

-identify provider
-date/ time (military)
-support ICD codes submitted
-all encounters (phone, fax, messaging)
-chart timely but not prior to occuring
-complete, concise, objective and accurate
-chart significant things
-use approved abbreviat

Define what the acronym HIPAA stands for and the purpose of the legislation.

Health Insurance Portability and Accountability Act of 1996 - ensure that health insurance eligibility was maintained when people changed or lost jobs that has evolved to set of rules that cover patient privacy

Define PHI and the Minimum Necessary Rule?

protected health information - generally the amount of PHI used, shared, accessed, or requested must be limited to only what is needed for the health care provider to do their job and fulfill their professional responsibilities for that patient

What is the purpose of the Patient Safety and Quality Improvement Act of 2005?

established a voluntary reporting system to assess and resolve patient safety and health care quality issues and encouraged reporting and analysis of medical errors without fear of increased liability risk

Success at avoiding litigious situations includes documentation, informed consent and disclosure. How do informed consent and appropriate disclosure play a role in reducing the likelihood of legal action by a patient and/or their families?

makes them part of team?