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Medical Record Keeping: A Comprehensive Guide for Optometrists, Exams of Advanced Education

A comprehensive guide to medical record keeping for optometrists, covering essential aspects such as record content, legal requirements, and best practices for maintaining accurate and complete documentation. It delves into the soap note format, outlining the importance of subjective, objective, assessment, and plan sections. The document also emphasizes the significance of proper record maintenance, including correction procedures and data security measures. It highlights the legal implications of record keeping and the importance of complying with hipaa regulations. This resource is valuable for optometry students and practitioners seeking to understand the intricacies of medical record management.

Typology: Exams

2024/2025

Available from 03/07/2025

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OPT 219 THE MEDICAL RECORD EXAM QUESTIONS AND
CORRECT ANSWERS!!
T or F: all optometric physicians have a professional obligation to maintain a complete
and accurate record for each patient.
True; failure to do so is a leading factor in malpractice allegations and professional
conduct hearings (results in a judgement against the doctor)
What governs the obligations by doctors to keep appropriate records?
federal and state law
What constitutes a valid record?
-may be hand written, typed, or electric
-chronology of care rendered
-documentation of: rationale for diagnosis, treatment or management plan, response to
treatment or management
What is meant by "complete" and "accurate"?
-the document must tell a story
-may be used in a number of ways for the benefit of the patient AND the practitioner
In what ways can a medical record be used to benefit both the patient and the doctor?
-care management
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Download Medical Record Keeping: A Comprehensive Guide for Optometrists and more Exams Advanced Education in PDF only on Docsity!

OPT 219 THE MEDICAL RECORD EXAM QUESTIONS AND

CORRECT ANSWERS!!

T or F: all optometric physicians have a professional obligation to maintain a complete and accurate record for each patient. True; failure to do so is a leading factor in malpractice allegations and professional conduct hearings (results in a judgement against the doctor)

What governs the obligations by doctors to keep appropriate records? federal and state law

What constitutes a valid record? -may be hand written, typed, or electric -chronology of care rendered -documentation of: rationale for diagnosis, treatment or management plan, response to treatment or management

What is meant by "complete" and "accurate"? -the document must tell a story -may be used in a number of ways for the benefit of the patient AND the practitioner

In what ways can a medical record be used to benefit both the patient and the doctor? -care management

-reimbursement -peer review -utilization management -litigation

What ARE medical records? -legal documents -used to communicate treatment plans between providers -used to evaluate your clinical performance (quality assurance) -an outward expression of your clinical rigor

What are medical records NOT? a place to editorialize

What is a SOAP note? subjective, objective, assessment, plan

Why should we use the soap format? -gave physicians rigor, structure, and a way for practiced to communicate with each other -able to retrieve patient records for a given medical problem

-complete chronology of past ocular history/findings -vital signs (VA, IOP) -clinical measurements, examinations, and gross observations -results from imaging or laboratory studies done during the course of examination

What is the assessment? medical diagnosis for the visit on the given date of a note written

What is the diagnosis rationale? summary of the subjective information gathered during the interview with the patient and the objective findings of the physical exam; consolidates these into a short assessment

What is a plan? should include anything that will be done to treat the patient as a consequence of the assessment

What should a plan include? -medications or treatment regimes prescribed -referrals if needed -orders for labs or special studies -instructions for continuation of care (ex= RTC)

What are the rules of law? -transparency -predictability -stability -enforceability/accountability -due process

T or F: most litigation in health care involves actions brought against the doctor by the patient

True; often litigated 3-5 years after the patient received treatment

______________ _______________are the only reliable, detailed account of what took place. medical records

What does the TN state board of optometry say about the duty of an optometrist to maintain records? as a component of the standard of care and of minimal competence, an optometrist must cause to be created and maintained an optometric record for every patient for whom he or she, and any of his or her supervisees performs services or provides professional consultation

What are the 4 types of data in patient records? -personal -financial

includes: -relevant records from other providers -referral letters and consultation results -diagnostic information -treatment information -the entire medical record

What types of data is included in medical data? -chief complaint -personal and family medical histories -exam results -assessment -treatment recommendations and plan -special patient circumstances or authorizations

What are the two types of errors that can occur? -minor -major

What are examples of minor errors? -transcription errors -minor spelling

What are examples of major errors? -omission of relevant data (test results, A/P) -inclusion of data not related to the patient

T or F: errors or mistakes in a patient record should be erased, obliterated, or deleted. False; they should never be changed because this arouses suspicion

How should corrections be made? in a way that facilitates seeing the change that was made AND indicated the identity of the individual making the change

How should corrections and alterations be made on paper records? -use a single line to mark through the incorrect entry -enter the correction -initial the correction -enter the date and time the correction was made

What types of personal data are included in electronic records? -exact method depends on the software -an audit trail is usually created

Where should a correction be made if an entry requires more space than what is available in the chart?

period of time, established by statute and measured in years, within which a party can bring a lawsuit against another party; it is a key factor in determining record retention policies

What are the 4 ways of obtaining PHI from providers? -medical records authorization -subpoena or discovery request with notice requirements -subpoena or discovery request with qualified protective order -judicial or administrative order

According to the state of TN, how long should optometric records be kept for? 10 years from the optometrist's or his supervisees last professional contact with the patient

What are exceptions for the rule above? -for incompetent patients, records should be kept indefinitely -for minors, shall be retained for a period of not less than 1 year after the minor reaches the age of maturity or 10 years from the last contact whichever is longer

T or F: No optometric record involving services under dispute shall be destroyed until the dispute is resolved True

Who owns the records once the doctor has been reimbursed for any services or

materials provided? the patient

but the doctor has an obligation to create the records and keep the records accurate (the doctor has the privilege/responsibility of maintaining them)

According to the state of TN, who owns hospital records? remains the property of the hospitals, subject to a court order to produce the records

Can patients be denied a copy of their records? No; with a few exceptions

Should patients be given the original record? No

What should be documented when a patient refuses a dilated eye exam? -you informed the patient of the medical need to dilate -you informed the patient of the risk of non detection -document that the patient fully understood your education -document that once fully informed, the patient continued their refusal

What should be documented to keep you out of trouble?