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PPO Final 1 > Recording Keeping Bullshit > Flashcards

Flashcards in Recording Keeping Bullshit Deck (11)
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1
Q

What does the problem oriented medical record (POMR) contain? 4 things

A
  1. the defined database
  2. the complete problem list
  3. initial treatment plans
  4. progress notes (SOAP notes)
2
Q

What is the Federal Trade Commission Eyeglasses Rule (FTC)

A

the pt has a right to obtain informatin related to his prescription for specs or contact lenses. give pt a copy even if they dont ask

3
Q

what are 4 things included in a comprehensive exam

A
  1. pt demographics
  2. results of the tests you do on all pts
  3. problem list
  4. plan list
4
Q

what is SOAP format

A

subjective - signs, symptons, reasons
objective - all testing
asessment - todays diagnosis
plan - future

5
Q

what kind of exam is the defined database used for

A

comprehensive examination

6
Q

what are progress notes used for

A

follow-up examinationsnon comprehensive exams

7
Q

what are 4 purposed of optometric records 1. facilitate ____2. provide______3. serve as -____4. justify _______

A
  1. facilitate pt management and good clinical decision making
  2. provide a current, comprehensive account of care and treatmetn
  3. serve as the doctor’s defense in court
  4. justify fees collected from 3rd parties such as insurance companies
8
Q

what should be in a record 1. _____ of visit 2. pt ______ and other ______3. _____ for visit 4. all ______ done and _________ including______5. VA always done _______ and at _____ visi t6. diagnosis/ _____7. treatment/ _____8. recommendations for _______9. speicific pt ______ given 10. ______ to whom and when 11. ________ with whom and when 12. all reports of any ______ w/ pt or about pt

A
  1. date of visit
  2. pt name and other demographic info
  3. reason for visit
  4. all testing done and test results including auxililary tests (see attached form)
  5. visual acuity ALWAYS done first at EVERY visit 6. diagnosis/assessment
  6. treatment/management plan
  7. follow-up care
  8. education
  9. referrals
  10. follow-ups
  11. communication
9
Q

what format are progress notes done in

A

SOAP format

10
Q

_____ is always done first at every visit

A

habitual VA

11
Q

what is rtc

A

return to clinic