When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment.
Full Answer
When a patient fails to return or needed treatment?
Subjective,Objective,Assessment, Plan When a patient fails to return or needed treatment, documentation should be made All of the above How should an entry in a patient's medical record be corrected Cross out the incorrect entry, substitute the correct information, date and initial the entry
What should be included in documentation of a patient's refusal of treatment?
When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment.
What are the reasons for documentation in medical records?
Reasons for documentation include - defense of a professional liability claim - insurance carriers require accurate documentation that supports procedure and diagnostic codes The SOAP in patient medical record charting may be defined as
How does a doctor discuss a treatment with a patient?
The physician held a discussion with the patient and the patient understood their medical condition, the proposed treatment, the expected benefits and outcome of the treatment and possible medical consequences/risks of refusal. Discharge or follow-up instructions.
What is an established patient?
An established patient is anyone who has previously received professional services from the physician or another physician of the same specialty who belongs to the group practice. A consultation may take place in a home, office, hospital, or extended care facility.
What is the chronological recording of pertinent facts and observations about the patient's health?
The chronological recording of pertinent facts and observations about the patient's health is known as. Documentation. Reasons for documentation are. Defense of professional liability claim, and insurance carriers require accurate documentation that supports procedure and diagnostic codes.
What is an electronic medical record?
An electronic medical record report is. Permanent legal document, and part of the health record. An advantage of electronic medical records is. greater standardization in clinical medical terminology. When each entry in the medical record is worded similar to the previous entries, this is considered documentation. Cloned.
What is referral in managed care?
In dealing with managed care plans, a referral is the. same as a consultation, and transfer of the total or specific care of a patient from one physician to another. When a discussion takes place with a patient concerning the risks and benefits of treatment options, it is considered. Counseling.
When a patient refuses medically indicated treatment, should documentation reflect that?
When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment. This documentation would validate ...
What should documentation reflect?
In addition, documentation should reflect that the physician attempted to provide the patient with appropriate discharge instructions and follow-up information. Documentation should include the following: The patient's capacity to understand the information being provided or discussed. Treatment was offered and refused.
What is the reason for refusing a treatment?
The reasons a patient refuses a treatment. The physician held a discussion with the patient and the patient understood their medical condition, the proposed treatment, the expected benefits and outcome of the treatment and possible medical consequences/risks of refusal. Discharge or follow-up instructions.