Term
| Preserving exam & test results in file, must be maintained after providing services |
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Definition
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Term
| What is an example of documenting? |
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Definition
| Case Hx & test outcomes on audiogram form (AC, BC, speech audiometry, acoustic immittance results) |
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Term
Documenting:
-Significance: Crucial for continuity of ___, billing, & ___
-Implications: be ___ |
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Definition
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Term
| Summarizing the documentation |
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Definition
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Term
Reporting:
-Interpreting & converting documented data into report form to ___ effectively
-Be succint (___ is more) |
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Definition
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Term
3 key ideas from Dr. Stach:
-___ and ___ language
*use ___ terminology
*Make it ___ and concise |
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Definition
| Simplify; standardize; consistent; clear |
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Term
3 Key idea from Dr. Stach:
2. Skip the term "___"
-“A report that says the outcome was “borderline normal” does ___ tell me anything” |
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Definition
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Term
3 Key ideas from Stach:
3. Communicate ___ results
-Report if anything is ___ |
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Definition
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Term
What if Reliable Responses Could Not be Obtained?
-___ on the audiogram that valid thresholds could not be established
-Write a ___
-Note: reliable means ___
-Note: valid means results are ___ (e.g. represent the
listener’s thresholds) |
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Definition
| note; letter; repeatable; true |
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Term
Medical Record Documentation: Purposes
-Determines ___ level
-Preserves health information to facilitate ___ care
-Keeps ___ data
-Maintains ___ data
-Helps meet ___
-___ health reporting |
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Definition
| reimbursement; current/future; injury; scientific; regulations; Public |
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Term
-Record is admissible as evidence in all personal ___
legal proceedings & forms basis of ___ of all malpractice cases
-Incomplete or inaccurate records raise ___ of fact about care
-Quality documentation deters ___
-Liability often imposed if ___ can not be established |
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Definition
| injury; defense; questions; lawsuits; facts |
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Term
Describe ways to reduce risk when documenting:
-Put patient’s ___ name on every page
-___, signature, ___ of practitioner on all entries
-Entries should be ___, juries often equate poor entries
with poor care
- Entries should be ___, objective, & ___ pertinent |
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Definition
| full; Date; title; legible; specific; clinically |
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