When the patient wants to discuss many problems with the physician?
Which of the following is the most appropriate action when the patient comes into the office for a singular problem and wants to discuss many problems with the physician? remind the patient that the physician's time is limited, but he will try and accommodate if possible.
Can a treating/billing provider verify a patient’s chief complaint?
The treating/billing provider should personally verify the patient’s chief complaint. For example, a patient may be embarrassed, or have other reasons not to share the “real” CC with ancillary staff, or to record it on a patient questionnaire or intake form.
Why is it important to understand the complex issues surrounding medication?
The complex issues surrounding the taking of medication for chronic disease cannot easily be distilled into one word. Recognition of this complexity will help avoid assigning blame exclusively to the patient and assist in identifying effective solutions.
Why do doctors ask patients what medications they are taking?
By asking the appropriate questions, physicians can accurately assess which medications patients are taking and how they are taking them. At a routine visit, patients may be asked twice to list their medications (eg, on a form while waiting to be seen and again when the nurse escorts them to the examination room).
What is the chief complaint in a medical record?
INTRODUCTION. A chief complaint is a concise statement in English or other natural language of the symptoms that caused a patient to seek medical care. A triage nurse or registration clerk records a patient's chief complaint at the very beginning of the medical care process (Figure 23.1 ).
What is the first and most important responsibility of the medical assistant when taking a medical history?
Which of the following best describes the first responsibility of the medical assistant when taking the medical history? Put the patient at ease. Which of the following is the most appropriate action when the patient comes into the office for a singular problem and wants to discuss many problems with the physician?
Which of the following is true about the chief complaint?
Which of the following is true about the chief complaint? It is a statement of objective findings made by the staff. It is determined by the provider after the physical exam.
How should the patient chief complaint be recorded in the medical record?
A chief complaint should comprise a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return or other factors that establish the reason for the encounter in the patient's own words (e.g., aching joints, rheumatoid arthritis, gout, fatigue, etc.).
What is the most important role of the medical assistant in the clinical setting and why what other duties may you have in an office or clinical setting?
One of your most important tasks as a medical assistant is keeping patient medical records current. You'll enter a patient's weight and blood pressure and their pre-exam interview responses into a computer database.
What is the responsibility of a medical assistant?
Medical Assistant: Assists physicians, nurses, and other medical staff by performing administrative and clinical duties under the direction of a physician. Administrative duties may include scheduling appointments, maintaining medical records.
What is chief complaint in nursing?
During a visit to a clinic or emergency department or on admission to a health care agency, the patient's reasons for seeking care are referred to as the chief complaint .
What is chief complaint in psychology?
The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter.
What is Chief main and additional secondary patient's complaints?
The chief complaint is a concise statement describing the symptom, problem, or condition that is the reason for a medical encounter. A secondary complaint is a second, less severe problem with the patient, which may or may not be directly related to the chief complaint.
Is medication refill a valid chief complaint?
At times Compliance has observed the CC documented as “follow up” or “med refill.” These are not appropriate chief complaints as they provide no clue as to the presenting problem. A more appropriate CC would include the reason for follow-up or the problem(s) associated with the need for medication refills.
Why is chief complaint important?
Chief complaints—also commonly referred to as presenting problems, clinical syndromes, or reasons for visit—are important because the chief complaint often guides diagnostic decision making and care. It is also a vital data element collected by regional and state public health systems to monitor for disease outbreaks.
Is a chief complaint required?
A chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter. A CC is required for all levels of service.
How does medication adherence affect the health of the population?
In its 2003 report on medication adherence,1the World Health Organization (WHO) quoted the statement by Haynes et al that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.” Among patients with chronic illness, approximately 50% do not take medications as prescribed.1,2This poor adherence to medication leads to increased morbidity and death and is estimated to incur costs of approximately $100 billion per year.3Thus, Hippocrates' exhortation to the physician to “not only be prepared to do what is right himself, but also to make the patient…cooperate”4has consistently failed for more than 2000 years. Today's ever more complicated medical regimens make it even less likely that physicians will be able to compel compliance and more important that they partner with patients in doing what is right together.
How many people do not take their medications?
Although these medications are effective in combating disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed.
How to measure medication adherence?
The following are some of the approaches that have been used: (1) subjective measurements obtained by asking patients, family members, caregivers, and physicians about the patient's medication use; (2) objective measurements obtained by counting pills, examining pharmacy refill records, or using electronic medication event monitoring systems; and (3) biochemical measurements obtained by adding a nontoxic marker to the medication and detect ing its presence in blood or urine or measurement of serum drug levels . Currently, a combination of these measures is used to assess adherence behavior. Along with the monitoring of outcome, these tools assist investigators in studying medication adherence.
What is the definition of adherence to long term therapy?
The WHO defines adherence to long-term therapy as “the extent to which a person's behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds
What are the complications of hypertension?
Cardiovascular complications resulting from hypertension, hyperlipidemia, and diabetes lead to substantial disability, morbidity, and mortality. For example, for every increase of 20 mm Hg in systolic BP and every increase of 10 mm Hg in diastolic BP, the risk of stroke and ischemic heart disease doubles.7Because of this increased risk, comprehensive treatment plans for patients with established CVD include antidiabetes, antihypertensive, and lipid-lowering (typically statin-based) therapies for patients who present with diabetes, hypertension, and dyslipidemia, respectively.8
What is the treatment for CVD?
Comprehensive treatment plans for patients with CVD also include indefinite use of antiplatelet therapy.8For patients with heart disease, ischemic cerebrovascular disease, or peripheral artery disease, aspirin or clopidogrel monotherapy has a favorable benefit-to-risk profile; for patients who experience an ischemic cerebrovascular event, therapy with aspirin plus extended-release dipyridamole is an additional treatment option.19For patients who experience acute coronary syndrome or undergo percutaneous coronary intervention with stent implantation, dual antiplatelet therapy with aspirin and either clopidogrel or prasugrel is recommended for at least 12 months for those not at a high risk of bleeding.20
How many articles were retrieved from Medline?
Of the 405 articles retrieved, those that did not address CVD, medication adherence, or health literacy in the abstract were excluded, leaving 127 for inclusion in the review. Additional references were obtained from citations within the retrieved articles.
What is a CPT complaint?
CPT defines the CC as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.”. Simply stated, the chief complaint is a description of why the patient is presenting for healthcare services. An easily identifiable chief complaint is the ...
What is preventive service?
A preventive service; or. Unbillable. The treating/billing provider should personally verify the patient’s chief complaint. For example, a patient may be embarrassed, or have other reasons not to share the “real” CC with ancillary staff, or to record it on a patient questionnaire or intake form.
Is preventive service acceptable?
As long as a preventive service is being billed it would be acceptable.
Do you need a chief complaint for preventive medicine?
Preventive medicine services (CPT® 99381-99387) do not require a chief complaint. Because a preventive medicine service is not problem-oriented, you should not diagnose it, as such. Instead, match preventive medicine codes with an appropriate ICD-9-CM code to support the services provided (e.g., V70.0 Routine general medical examination ...
Is CC a part of HPI?
Do not confuse the CC with the history of present illness (HPI);they are separate elements. The CC is the reason why the patient is there. The HPI details the CC. Although the CC directs the line of questioning in the HPI and the Review of Systems (ROS), the extent of history obtained should not be more than is medically necessary to evaluate the patient. According to the CMS Evaluation and Management Services Guide, “The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness.”
