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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
-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?
