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Clinical Scribe Accelerator Training (CSAT) Workbook

Family Practice

By Brenna Bray, PhD

ScribeConnect, LLC

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This is a preview of copyright materials. The number of pages displayed is limited. This material is not to be used for personal gain, corporate gain, or financial profit.

Clinical Scribe Accelerator Training (CSAT) WorkbookFamily Practice

Copyright © 2019 by ScribeConnect, LLC

All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means including

photocopying, recording, or information storage and retrieval without prior written permission from the author or publisher.

ISBN-13: 978-1-7333310-1-2

www.scribeACCELERATOR.com

Proide feeback on the workbook at [email protected]

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Table of Contents – Brief Overview

Front Matter

Table of Contents – Brief Overview ................................................................................................ ivWhat is a Clinical Scribe? .................................................................................................................. viScribeConnect’s Clinical Scribe Accelerator Training (CSAT) Platform .............................. viiWhy Choose CSAT ................................................................................................................................. ixAbout This Workbook: ......................................................................................................................... xAcknowledgments: ............................................................................................................................... xiAbout the Author .................................................................................................................................. xii

Module I: IntroductionModule I - Table of Contents – In Detail .............................................................................................. 1

Chapter 1 Introduction ....................................................................................................................... 3Chapter 2 The Clinical Scribe Role ................................................................................................ 15Chapter 3 Workflow in the Clinical Environment ..................................................................... 27Chapter 4 A Typical Scribe Shift ...................................................................................................... 35Chapter 5 Industry Regulations: HIPAA & HITECH ................................................................... 51References Module I ............................................................................................................................ 66

Module II: Medical DocumentationModule II - Table of Contents – In Detail ............................................................................................. 71

Chapter 6 The Provider SOAP Note ................................................................................................ 74Chapter 7 Example Provider Note .................................................................................................. 102Chapter 8 Medical Terminology & Pathology ............................................................................ 110Chapter 9 Diagnostic Laboratory Studies .................................................................................... 170Chapter 10 Diagnostic Imaging Studies ....................................................................................... 209Chapter 11 Medical Procedures ...................................................................................................... 236References Module II .......................................................................................................................... 257

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Module III: Coding, Billing, & ReimbursementModule III - Table of Contents – In Detail............................................................................................ 259

Chapter 12 Healthcare Industry: Historical Overview ............................................................. 262Chapter 13 MACRA & QPPs .............................................................................................................. 284Chapter 14 E/M Coding: ICD, HCPCS, & CPT ............................................................................... 325Chapter 15 E/M Coding in Depth .................................................................................................... 358Chapter 16 The Scribe Role in Medical Coding ......................................................................... 417References Module III ......................................................................................................................... 434

Module IV: Medico-Legal DocumentationModule IV - Table of Contents – In Detail ........................................................................................... 443

Chapter 17 Two-Fold Legal Aspects of Medical Documentation ......................................... 445Chapter 18 Legal Regulations .......................................................................................................... 448Chapter 19 Medicolegal Documentation ..................................................................................... 464Chapter 20 Documentation (I): Audits & Amendments .......................................................... 473Chapter 21 Medicolegal Documentation (II): The Expanded SOOOAAP Note ................ 489Chapter 22 Malpractice Prevention ............................................................................................... 504References Module IV ......................................................................................................................... 517

AppendicesAppendices Table of Contents ................................................................................................................. A.1

A.I Scribe Integration Resources .................................................................................................... A.I.2A.II Provider Preference Documents .............................................................................................. A.II.6A.III Family Medicine Documentation Basics ............................................................................ A.III.20A.IV Documentation Basics for Common Chief Complaints in Family Medicine ........... A.IV.28A.V Documentation Basics for Preventive Measures in Family Medicine ......................... A.V.41A.VI E/M Level Coding Chart ........................................................................................................... A.VI.48A.VII Hierarchical Condition Category Coding and Risk Adjustment Factors (HCC & RAFs) ........... A.VII.50A.VIII HIPAA & HITECH – In Greater Depth ...............................................................................A.VIII. 51A.IX Medical Terminology .................................................................................................................. A.IX.52A.X Medical Abbreviations ................................................................................................................ A.X.67A.XI Scribe Documentation Tips for Meeting Regulatory Standards (NPS, MIPS, & TJC) ... A.XI.77A.XII Workbook: Answer Key ............................................................................................................. A.XII.81

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A Clinical Scribe is an unlicensed, certified, or licensed individual (ex: MAs, CNAs, RNs, etc.) who provides documentation assistance to physicians or other licensed independent practitioners (ex: MDs, PAs, LPNs) in the clinical setting. Clinical Scribes work one-on-one with a medical provider during each shift to assist with medical record documentation and electronic health record (EHR) system navigation “in real time.”

While clerical in nature, the scribe role extends far beyond secretarial duties.

SuperScribe Tip: Clinical Scribes vs Medical Scribes

The roles of the Medical and Clinical Scribe and essentially the same. CSAT materials use the term “Clinical Scribe” because this term more accurately reflects the active clinical environment in which the scribe role functions. Furthermore, most CSAT students enter with an allied health background and have pre-existing experience, certifications, and/or licensure in the clinical healthcare setting. The term “Clinical Scribe” reflects the expanded roles of these dually-certified scribes, whose scopes often exceed those of a traditional Medical Scribe with more restricted/limited job descriptions. This CSAT course provides education and training for anyone who wants to work in the clinical setting as a Medical or Clinical Scribe (with or without pre-existing clinical experience, certifications, or licensure).

Clinical Scribes are permitted to:

h Capture and document information from the patient-provider encounter h Document the electronic medical record (EMR) for each patient seen h Assist the provider in navigating the electronic health record (EHR) system h Locate and obtain past patient files, as deemed medically necessary h Retrieve and document laboratory, radiology, and procedural findings h Document aspects of Medical Decision Making (MDM)

These and other scribe duties require basic education and training in the following “minimum core competencies,” as identified by the Joint Commission (TJC), an independent health care accreditation and certification organization (2018):

h Medical Terminology h Health Insurance Portability and Accountability Act of 1996 (HIPAA) h Principles of billing, coding, and reimbursement h Electronic Medical Record (EMR) navigation and functionality h Computerized order entry, clinical decision support, and proper methods for pending orders for authentication and submission.

What is a Clinical Scribe?

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ScribeConnect’s Clinical Scribe Accelerator Training (CSAT) Platform provides unlicensed, certified, and licensed individuals with the training they need to become successful medical scribes.The Clinical Scribe Accelerator Training (CSAT) Platform provides healthcare organizations and practitioners with the resources they need to effectively train and implement medical scribes into their respective clinical settings.

The CSAT Platform provides a comprehensive four-phase training program:

h Phase I: Classroom Training

h Phase II: Electronic Health Record (EHR) System Training

h Phase III: Clinical Training

h Phase IV: Clinical Evaluation

This comprehensive four-phase format exceeds the Joint Commission’s 2018 Guidelines for Clinical Scribe Education and Training, and provides the only academically-driven scribe training program available on the market today.

Phase I: Classroom Training Resources are all organized into four modules that cover The Four Pillars of Clinical Documentation:

h Pillar I (Module I): General & Regulatory Aspects of Clinical Documentation

h Pillar II (Module II): Medical Aspects of Clinical Documentation

h Pillar III (Module III): Financial & Business Aspects of Clinical Documentation

h Pillar IV (Module IV): Legal Aspects of Clinical Documentation

ScribeConnect’s Clinical Scribe Accelerator Training (CSAT) Platform

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Phase I CSAT Resources Include:

The Phase I CSAT Course (20 hrs.)

9 Four modules emphasizes the Four Pillars of Clinical Documentation

9 Each course module contains 4 – 6 Chapter Units and includes:

9 Medical Vignettes

9 End-of-Chapter Review & Assessment Sections

9 End-of-Chapter Quizzes

9 Administration and Documentation Resources

9 Final Examination

9 CSAT Phase I Certification provided to students who earn >95% on the Final Examination

9 Available online at: www.ScribeACCELERATOR.com

The Phase I CSAT Textbook & eBook (400 pgs.) 9 Provides text content for the Phase I CSAT Course

9 Four modules emphasizes the Four Pillars of Clinical Documentation

9 Each module contains 4 – 6 Chapters that include:

9 Medical Vignettes

9 End-of-Chapter Review & Assessment Sections

9 Administration and Documentation Resources

9 Available online at: www.ScribeACCELERATOR.com

The Phase I CSAT Workbook & eWorkbook (400 pgs.) 9 Supplements the Phase I eCourse and/or Textbook

9 Includes Review Sections for each Chapter

9 Extensive End-of-Chapter Assessment and Quiz Materials

9 Includes Appendix and Answer Key (150 pgs.)

9 Available Online at www.ScribeACCELERATOR.com

By combining academic research and industry experience, ScribeConnect’s CSAT Platform provides healthcare administrators and providers with all the resources needed to successfully train and implement medical scribes into the clinical healthcare setting.

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Research demonstrates that clinical (medical) scribes have an overall positive effect on clinical workflow, provider care, charting and documentation, and provider- and patient satisfaction. Unfortunately, many healthcare organizations and practitioners lack the appropriate resources to successfully implement medical scribes into their current clinical workflow.

ScribeConnect is a national full-service medical scribe training, management, and staffing company with over 7 years of success in the medical scribe industry (www.scribeconnect.com). In response to an overwhelming demand for clinical scribe services, ScribeConnect has now made their proprietary training materials available online through the Clinical Scribe Accelerator Training (CSAT) platform.

The CSAT Platform provides a comprehensive four-phase training program:

h Phase I: Classroom Training

h Phase II: Electronic Health Record (EHR) System Training

h Phase III: Clinical Training

h Phase IV: Clinical Evaluation

Phase I: Classroom Training Resources are all organized into four modules that cover The Four Pillars of Clinical Documentation:

h Pillar I (Module I): General & Regulatory Aspects of Clinical Documentation

h Pillar II (Module II): Medical Aspects of Clinical Documentation

h Pillar III (Module III): Financial & Business Aspects of Clinical Documentation

h Pillar IV (Module IV): Legal Aspects of Clinical Documentation

This comprehensive four-phase format exceeds the Joint Commission’s 2018 Guidelines for Clinical Scribe Education and Training, and provides the only academically-driven scribe training program available on the market today.

Why Choose CSAT

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The Clinical Scribe Accelerator Training (CSAT) Workbook provides healthcare organizations and practitioners with the resources they need to effectively train and implement medical scribes into their respective clinical healthcare settings.

The CSAT Workbook is designed to supplement the CSAT Phase I eCourse and eTextbook. The Workbook contains 417 pages of Review & Assessment Resources for each of the 22 Chapter Units covered in the CSAT eCourse and Textbook.

The CSAT Workbook also provides the only academically-driven scribe training resource available on the market today!

CSAT Workbook Content Includes: h Review Sections that highlight the most important information covered in each

Chapter/Unit of the eCourse and eTextbook

h Recommended Homework and Academic Resource References for all 22 Chapters

h Extensive Assessment and Quiz Materials for each Chapter Unit, including:

9 Multiple Choice Questions

9 Fill-in-the-blank Questions

9 Short Answer Questions

9 Open-Ended Questions

h Complete Answer Key (150pgs)

h eTextbook Appendix Materials, including:

9 Administration Resources

9 Documentation Resources

9 Medical Terminology List

9 Medical Abbreviations List

Overall, the CSAT Workbook prepares CSAT students to exceed the Joint Commission’s 2018 Guidelines for Clinical Scribe Education and Training, and ace the CSAT Phase I Certification examination!

About This Workbook:

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Brenna Bray, PhD is the Director of Operations for ScribeConnect’s Clinical Scribe Accelerator Training (CSAT) Platform and the primary author of all CSAT materials. She holds a PhD in Biomedical Sciences and Neuroscience from Sanford School of Medicine at the University of South Dakota and a certification in publishing from the Denver University Publishing Institute (DUPI). Dr. Bray has 4+ years of middle and upper management experience in the Clinical Scribe industry as well as 2 years of experience in the Textbook Publishing Industry. She is a well-published author and a member of the American Medical Writers Association (AMWA) and the American Health Information Management Association (AHIMA). Dr. Bray also enjoys running ultra-marathons and boasts a 50k race time of 4:11.

ScribeConnect would also like to thank the following contributors:

Dan Doolittle, MD is an Emergency Medicine physician in Mount Vernon, Illinois. Dr. Doolittle has over 30 years of experience practicing Emergency Medicine and is affiliated with affiliated with multiple hospitals in the Illinois area. He received his medical degree from Hahnemann University School of Medicine.

Victoria Menchaca, BBA, CCS, CCS-P, CIRCC, CICA, CMARS, CPC-I is a Certified Coding Specialist and Senior Reimbursement Consultant at Reimbursement Specialists with over 20 years of health care experience. Menchaca specializes in coding, compliance, and reimbursement products, and assists clients with Clinical Documentation Improvement. Menchaca holds a bachelor’s degree in Business Administration (BBA) and holds certifications in Interventional Radiology Medical Coding and Professional Coding Instruction (CPC-I). Menchaca is also a nationally sought speaker on coding and reimbursement topics and has contributed to Medicare Part B News publications as an expert coder.

Muhammad Rahmi Mowjood, DO, FACOFP, is a founding partner and current CEO of Cucamonga Valley Medical Group [CVMG]. Dr. Mowjood is a graduate of Western University of Health Science’s College of Osteopathic Medicine and completed his Family Medicine residency at Arrowhead Regional Medical Center. Prior to starting CVMG, Dr. Mowjood was an Assistant Professor of

About the Author

Acknowledgments:

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Family Medicine at Western University. He also serves as Medical Director for Medical Safety and Management as well as for PrimeCare/NAMM.

Joyce Park has 3 years of experience in clinical scribe training management in the Family Practice and Internal Medicine settings. Park provided critical help in authoring and editing the fifth edition of the CSAT Textbook.Andrew Park is an MD Candidate attending the University of California, San Diego School of Medicine. He has 2+ years of upper management experience in the medical scribe industry and assisted in the development of the CSAT training and educational programs. His professional interests include Emergency Medicine and drug addiction.

Sydnie Richendollar, MBA is a healthcare professional with 5+ years of experience and leadership in the medical scribe industry. She provided excellent contributions to the first and second editions of the CSAT Textbook.

Syeldy Sasongko, MA has 3 years of experience in the clinical scribe industry, including middle and upper management, in the multiple clinical settings, including Family Medicine, Emergency Medicine, Orthopedics, Obstetrics and Gynecology, Neurology, and Neurosurgery. Sasongko also holds a Research Masters in Global Health and is currently a PhD student in Sanquin, the National Blood Bank of the Netherlands.

Kyle Smart, DO, ABFM is a Founding Partner and current Chief Medical Officer at the Cucamonga Valley Medical Group (CVMG) in California. Dr. Smart has over 15 years of experience in Family Medicine, and also has experience practicing in Emergency Medicine and Urgent Care settings. Dr. Smart earned his DO from Western University of Health Sciences and completed his residency at Arrowhead Regional Medical Center in California. He is a proud father of four daughters. Dr. Smart enjoys participating in medical relief trips abroad.SAMPLE

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Module I:Introduction

Chapter 1. Introduction

Chapter 2. The Scribe Role

Chapter 3. Clinical Work Flow

Chapter 4. A Typical Scribe Shift

Chapter 5. Industry Regulations (HIPAA & HITECH)

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Module I - Table of Contents – In Detail

Chapter 1: Introduction ............................................................................................................................. 3

Introduction ............................................................................................................................................ 4Recommended Resources .................................................................................................................. 4Review ...................................................................................................................................................... 7Assessment (8 Questions) ................................................................................................................. 11

Chapter 2: The Scribe Role ....................................................................................................................... 15

The Clinical Scribe Role ..................................................................................................................... 16Recommended Resources .................................................................................................................. 16Review ...................................................................................................................................................... 19Assessment (20 Questions) ............................................................................................................... 23

Chapter 3: Clinical Work Flow ................................................................................................................. 27

Workflow in the Clinical Environment .......................................................................................... 28Recommended Resources .................................................................................................................. 28Review ...................................................................................................................................................... 29Assessment (14 Questions) ............................................................................................................... 32

Chapter 4: A Typical Scribe Shift ............................................................................................................ 35

A Typical Scribe Shift ........................................................................................................................... 36Recommended Resources .................................................................................................................. 36Review ...................................................................................................................................................... 37Assessment #1 (24 Questions) ........................................................................................................ 39Assessment #2 (16 Questions) ........................................................................................................ 47

Chapter 5: Industry Regulations (HIPAA & HITECH) ....................................................................... 51

Industry Regulations: HIPAA & HITECH ....................................................................................... 52Recommended Resources .................................................................................................................. 52Review ...................................................................................................................................................... 54Assessment # 1 (14 Questions) ....................................................................................................... 57Assessment # 2 (21 Questions) ....................................................................................................... 62

References Module I: .................................................................................................................66

1

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1Introduction

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Chapter 1: Introduction

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Chapter 1 Recommended Resources

The following resources are strongly recommended as homework reading for the CSAT eCourse and Textbook. Content from these resources will be used in the CSAT eCourse end-of-unit quizzes and Final Examination.

1. Chapter 1 of the CSAT Course

h The CSAT Course provides an excellent supplement to this chapter. The video segments help reinforce the content covered in this chapter and the end-of-chapter quizzes provide real-time assessment and feedback designed to help strengthen your scribe education and training.

h The CSAT Course also provides the opportunity to take a final examination and earn STAGE I CSAT Certification.

h Available online at: www.ScribeACCELERATOR.com.

2. Chapter 1 of the CSAT Workbook

h The CSAT Workbook provides extensive end-of-chapter assessment questions and an answer key that are designed to help strengthen your scribe education and training. The CSAT Workbook provides in-depth preparation for the STAGE I Examination, which is required to earn CSAT STAGE I Certification.


3. Campbell LL, Case D, Crocker JE, et al. Using medical scribes in a physician practice. Journal of AHIMA / American Health Information Management Association. 2012;83(11):64-69.

h Recommendations for scribe roles and responsibilities

h Scribe legal considerations

h Scribe documentation guidelines and implementation policies

h Common documentation duties for medical scribes

Introduction

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Chapter 1 Review

1. The Joint Commission (TJC), an independent healthcare accrediting agency, suggest that documentation assistants (Medical Scribes) receive education or training in the following minimum core competencies¹:

h Medical Terminology

h Health Insurance Portability and Accountability Act of 1996 (HIPAA)

h Principles of billing, coding, and reimbursement

h Electronic Medical Record (EMR) navigation and functionality

h Computerized order entry, clinical decision support, and proper methods for pending orders for authentication and submission.

2. ScribeConnect’s CSAT Platform provides education that extends beyond TJC’s minimum competencies. We cover what we term “The Four Pillars of Medical Documentation,” which refer to the four main aspects of medical documentation:

h General

h Medical

h Financial (including billing, coding, and reimbursement)

h Legal

The four modules in the CSAT platform provide primary Subject (Content) Information on each of the “Four Pillars.”

3. The Scribe role is clerical in nature; however, a scribe is much more than a secretary1-9.

Scribes must demonstrate proficient Subject Knowledge of the “four pillars” of medical documentation. Scribes must also be able to “think on their feet” and apply this knowledge to the active and dynamic Clinical Scribe Role while working one-on-one with a Provider, and as part of a team of medical professionals within the clinical setting. This second component of the scribe role requires Critical Thinking Skills, as addressed below.

4. PHASE I of the ScribeConnect CSAT Platform focuses on Subject Knowledge that is fundamental to the scribe role and includes Critical Thinking Applications. However, scribes are encouraged to follow PHASE I training with EHR-Specific Training (PHASE II), Workflow Training (PHASE III), and a 90-day evaluation period (PHASE IV)1,3,9-11.

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Chapter 1 Assessment (8 Questions)

1. What are the “Four Pillars” of medical documentation?

a. _____________________________________

b. _____________________________________

c. _____________________________________

d. _____________________________________

2. What are the 5 minimum core competencies that documentation assistants (medical scribes) must receive education or training in, according to the Joint Commission?

a. _____________________________________

b. _____________________________________

c. _____________________________________

d. _____________________________________

e. _____________________________________

3. The Introduction presents four different phases of Clinical Scribe Accelerated Training (CSAT). What are the four different phases of Clinical Scribe Training? What Phase(s) of Training does this CSAT Workbook assist in? Do you have a plan in place to receive the Training Phases that are not provided in this CSAT phase?

a. _____________________________________

b. _____________________________________

c. _____________________________________

d. _____________________________________

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Chapter 2: The Scribe Role

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2The Scribe Role

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Chapter 2 Review

1. The Scribe Role: Scribes work one-on-one with providers to perform “real time” documentation. Scribes enter patient rooms with the provider and capture pertinent information from each patient encounter to enter into each patient chart within the facility’s electronic health record (EHR) system. This is done under the direction of the provider. From a provider’s standpoint, scribes interact with the EHR system for the providers, enabling the providers to increase face time spent with the patients, and focus their attention on medical decision-making processes.

2. In brief, scribes help providers ensure and improve:

h Patient care and satisfaction, by improving documentation

h Patient wait times and throughput

h Number of patients seen per provider shift

h Depth and accuracy of documentation

h Legal protection

h Provider’s personal satisfaction

3. The terms Electronic Medical Record (EMR) and Electronic Health Record (EHR) may be used interchangeably in some medical settings; however, their exact definitions are important to understand:

h Electronic Medical Record (EMR) constitutes the patient’s health record relative to just one facility (including provider notes from all of a patient’s visits at one particular facility, such as the patient’s primary care clinic)25.

h Electronic Health Record (EHR) “a summary of health events (usually drawn from several EMRs) and may consist of the elements that are eventually shared in a national EHR25.” The EHR thus constitutes the patient’s entire health record, which is easily transferrable between medical facilities and other sources26,27.

4. The Joint Commission (TJC) identifies Clinical Scribes as unlicensed-, certified- (medical assistants (MAs) or technicians), or licensed (certified nursing assistants (CNAs), registered nurses (RNs)) individuals who provide documentation assistance to physicians (MDs) or other licensed independent practitioners (such as physician’s assistants (PAs) or licensed nurse practitioners (LPNs)), consistent with the roles and responsibilities defined in the scribe job description, and within the scope of the scribe’s certification or licensure1.

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1. What is The Joint Commission? You may need to conduct outside research or read ahead in the manual to answer this question.

2. What is the Joint Commission’s most up to date (2018) definition of a medical scribe?

3. Describe the scribe role:

4. Identify three components of scribe training and competency that the Joint Commission suggest be viewed as mandatory:

5. Define the following acronyms:

a. TJC:

b. EMR:

c. EHR:

6. What is an EMR?

7. What is an EHR?

8. What is the difference between EMR vs EHR?

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14. What are some implementation policies and procedure that ScribeConnect suggest?

15. What are some issues that should be addressed during the first 1 – 3 months of new scribe integration into the clinical environment?

16. Identify 5 vocabulary words presented in this chapter that you are unfamiliar with; look up the definitions for these words:

17. Review point #9 suggests reading Yan et al.’s 2016 research article, “Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care5,” which can be accessed online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978677/pdf/11606_2016_Article_3719.pdf. Read this article. What are 5 attributes that Yan et al., identified that were helpful in facilitating smooth integration of the new clinical scribe role into the existing clinical workflow?

18. What are 3 barriers/limitations that Yan et al. identified that were helpful in facilitating smooth integration of the new clinical scribe role into the existing clinical workflow?

19. How can you use the attributes that Yan et al. identify in your own role as an independent clinical scribe? How can you avoid- or prepare to overcome some of the barriers/limitations that Yan et al identify?

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20. Review point #8 suggests reading Martel et al.’s 2018 research article, “Developing a Medical Scribe Program at an Academic Hospital: The Hennepin County Medical Center Experience3,” which can be accessed online at: https://www.jointcommissionjournal.com/article/S1553-7250(17)30432-4/fulltext. Read this article and its supplementary material. Identify one implementation policy, process, or procedure from each of the categories listed below that Martel et al. used while developing their “home-grown” scribe program at HCMC:

i. Clinical Assessment and Preparation:

ii. Documentation Development and Preparation:

iii. Rollout Plan:

iv. Identifying Leadership:

v. Human Resources:

vi. Orientation and Training:

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Chapter 3: Clinical Work Flow

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3Clinical Work Flow

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Chapter 4: A Typical Scribe Shift

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4A Typical Scribe Shift

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4. Provider Preference resources in Appendix A.II

h Also available in the resources tab of the CSAT website

h www.scribeACCELERATOR.com

Chapter 4 Review

1. Arriving at least 30 minutes prior to the start of each shift enables the scribe to adequately prepare for the shift by:

h “Pre-charting:” preparing each patient’s Electronic Medical Record (EMR) within the facility’s Electronic Health Record (EHR) System.

h Prepare to comply with the provider’s specific preferences related to scribe use, charting, and documentation.

2. Independent scribes and scribe supervisors are encouraged to prepare documents for each provider that outline that provider’s specific documentation preferences. Examples of these documents are available in Appendix A.II and under the resources tab of the CSAT website (www.scribeACCELERATOR.com).

3. “Pre-charting” entails:

h Preparing each patient’s Electronic Medical Record (EMR) within the facility’s Electronic Health Record (EHR) System

h Verifying patient Personal, Family, and Social History (PFSH)

h Reviewing previous charting that may be pertinent to the patient’s present encounter, such as previous laboratory and radiology findings

h Pulling up specific EHR documentation aids that may otherwise take time to pull up and prepare during a shift

h Updating preventative healthcare measures

4. Scribes are encouraged to demonstrate initiative by identifying themselves to the provider as the scribe assigned to work with the provider for a shift.

5. New patients may require additional documentation. The scribe may be asked to enter information from new patient documents into the patient’s chart.

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6. Patient wait times are important. Most Family Practice settings have a goal for a provider to see each patient within 15 minutes of the patient’s arrival to the facility.

7. Pertinent patient history and subjective documentation criteria may be obtained by a nurse, Medical Assistant (MA), or through patient paperwork provided prior to the patient-provider encounter. The scribe may be responsible for reviewing and updating this information. This information may include the subjective portions of the patient’s chart:

h Chief Complaint (CC)

h History of Present Illness (HPI)

h Past, Family, and Social History (PFSH)

h Review of symptoms by body system (Review of Systems, ROS)

8. During the initial patient-provider encounter, the scribe will document pertinent information from the patient-provider interaction. This information will include:

h The subjective portions of the patient’s chart:

– History of Present Illness (HPI)

– Past, Family, and Social History (PFSH)

– Review of symptoms by body system (ROS)

h The objective portions of the patient’s chart:

– Physical Examination (PE)

h The plan of care, which may include:

– Laboratory studies

– Radiology studies

– Interventions, such as medications

– Procedures

h The patient’s agreement and consent with the provider’s plan.

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9. In 2015, Donna Vanderpool, MPA, JD, published a helpful article in the Journal of Innovative Clinical Neuroscience titled “EHR Documentation: How to Keep Your Patients Safe, Keep Your Hard-Earned Money, and Stay Out of Court43.” This article can be accessed online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558790/pdf/icns_12_7-8_34.pdf and we suggest all clinical scribes and scribe supervisors read this article during their Stage I clinical scribe training.

10. Many scribes find it helpful to designate an appropriate place and time after each patient encounter to ask the provider for any clarification needed relative to charting and documentation. This should be established prior to starting the shift.

11. The scribe will document each patient’s assessment and plan, as directed by the provider, and may enter the patient’s summary instructions into the EMR.

12. Time management and organization enable practical intelligence; these qualities are critical for a successful shift as an independent scribe.

h Resources on successful integration of new scribe roles into the existing work flow are available on the CSAT Website under the Resources tab.

13. Upon completion of each shift, the scribe is responsible for confirming the shift’s termination with the provider.

14. The scribe’s primary purpose is to provide quality service to the provider.

Chapter 4 Assessment #1 (24 Questions)

Questions 1 – 10 pertain to a scenario in which you are scheduled to work an 8am shift with Dr. Smith. These questions are designed to help you identify what time you will set your alarm clock to wake up that morning, and how you will prepare for your 8am shift.

NOTE: These are open-ended questions designed to promote proactive planning and preparation. Responses will vary according to the individual. Below, we have provided some important considerations that we hope you will use to calculate what time you will need to wake up before an 8am shift.

1. In addition to the 30 minutes of pre-shift preparation described in Review section #3 of this chapter, you will want to provide an extra 10-15 minutes to park your vehicle and comfortably enter your facility’s clinic.

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2. You will want to factor in transportation time. How long do you anticipate your commute from home to work will take?

3. You will want to factor in transportation time. Given your 8a shift start time, are you likely to run into traffic, and will this alter the time of your commute?

4. You will want to factor in transportation time. Will you need to stop for gasoline or a morning coffee?

5. You will want to factor in transportation time. We suggest planning an additional 15 minutes of commute time to account for unexpected traffic or transportation issues.

Questions 6 – 10 are designed to help you identify the amount of time you will need at home to prepare for the day, from the time you wake up to the time you walk out your front door.

6. Scribe hygiene is important. Do you have a uniform you are required to wear as a scribe, and if so, is it clean and ready to be worn?

7. Scribe hygiene is important. Do you shower in the morning or evening? If you plan to shower before your shift, how long do you anticipate this will take?

8. Scribe sustenance and hydration are important. Do you have a usual pre-work breakfast routine? If so, how long do you anticipate this will take?

9. Scribe sustenance and hydration are important. Do you have a lunch and/or snack(s) prepared to bring with you during your shift? If you plan to prepare these before you leave your house in the morning, how long do you anticipate this preparation time will take?

10. Hydration is critical in the clinical setting; we recommend bringing 32-64oz of water with you per 8-hour shift.

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11. Why is it important to arrive early to each shift? Arriving at least 30 minutes early prior to the start of each shift provides time for a scribe to (select all answers that apply):

a. Prepare for an efficient shift

b. Park and enter into the facility

c. Clock in using the facility’s time card system

d. Log in to the scribe workstation and log on to the facility’s electronic health record system

e. View the current work flow, pace, and schedule for the day

f. Prepare each patient’s Electronic Medical Record (EMR) within the facility’s Electronic Health Record (EHR) System (“Pre-charting”)

g. Review Provider Preferences related to scribe use, charting, and documentation

h. Go to the bathroom as needed

i. Greet the provider with an introduction upon arrival

j. Efficient preparation prior to the start of each clinical shift enables each scribe to assess the work pace and flow for the shift and formulate an initial assessment of time management requirements for that shift.

12. “Pre-charting” entails (select all that apply):

a. Preparing each patient’s Electronic Medical Record (EMR) within the facility’s Electronic Health Record (EHR) System (such as starting a new provider note)

b. Verifying patient Personal, Family, and Social History (PFSH)

c. Reviewing previous charting that may be pertinent to the patient’s present encounter, such as previous laboratory and radiology findings the provider may ask you to pull up

d. Pulling up specific EHR documentation aids that may otherwise take time to pull up and prepare during a shift

e. Completing an HPI template and entering this into the patient note

f. Copy/pasting the patient’s previous note into a new provider note

g. Copy/pasting the patient’s previous plan of care or discharge instructions into the “patient summary” for the current visit

h. Updating preventative healthcare measures

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13. Complete this statement by selecting all responses that apply. Pre-charting practices like the use of templates and auto/pre-population features can be helpful; however, they can also cause false documentation, which can:

a. Hinder quality patient care

b. Impose harm to the patient

c. Constitute documentation fraud

d. Increase risk for medical malpractice

14. Which of the following examples convey limitations or risks involved in “pre-charting?” Select all that apply.

a. Templates can populate information into a patient’s medical record that is not provided during the encounter, and so does not below in the medical record, unless verified by the provider with documentation of provider verification.

h Ex: A review of systems template phrase may state “all other systems are reviewed and are negative.” This phrase only belongs in a patient’s medical record if all other systems have indeed been reviewed and found to be negative.

b. Templates can populate information into a patient’s medical record that is inaccurate (such as populating an incorrect patient age, gender, mental status, etc.).

h Ex: A template may include a phrase such as “patient is afebrile” without taking patient temperature into account.

c. Like templates, auto/pre-population features and techniques can populate information into a patient’s medical record that is not provided during the encounter, and so does not below in the medical record, unless verified by the provider with documentation of provider verification.

h Ex: If a patient’s problem list, medication list, or health status is pre-populated into a patient’s medical record without verification first.

d. Like templates, auto/pre-population features and techniques can populate information into a patient’s medical record that is inaccurate.

h Ex: Populating female pelvic examination findings into the medical record of a male patient.

e. If patient information is accessed that is not necessary for the purposes of documenting the patient’s current patient-provider encounter, this can constitute a violation of the HIPAA Privacy Law

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15. How will you avoid the risks associated with pre-charting in your role as an independent clinical scribe? Select all that apply.

a. Use pre-charting practices to identify different items of medical documentation that should be attended to and updated these items during the encounter.

b. Use pre-charting to prepare for a patient encounter by pulling up information from old medical records that a provider may benefit from having access to during the patient encounter, but avoid pre-populating information before the patient encounter.

c. Use pre-charting practices only to gain an initial familiarity with each patient’s medical record – and only to the extent that this familiarity is necessary for your current documentation duties.

d. Do not rely on templates, pre-/auto-population features, or pre-charting practices for the majority of your documentation.

e. When using templates or auto/pre-population features, check to ensure that all template or auto-populated information is accurate and appropriate, including patient age, gender, mental status, etc.

f. Ensure that all auto/pre-populated documentation information is verified by the provider and patient during the patient encounter, and updated for accuracy.

g. Do not use pre-charting to add information into a patient’s chart that has not been verified by the provider or patient. This can hinder quality patient care, impose harm to the patient, and can constitute documentation fraud.

h. If you do include information in a patient’s medical record that is auto/pre-populated from an old medical record, or that was discovered through review of old medical records and was not verified during the patient encounter, include a qualifying statement indicating that this information was obtained from old medical records and was not verified during the patient encounter.

h For example: “review of patient’s old medical records reveals that patient has a history of …”

i. Do not use pre-charting.

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16. In 2015, Donna Vanderpool, MPA, JD, published an article on the regulatory risks of electronic medial documentation titled: “EHR Documentation: How to Keep Your Patients Safe, Keep Your Hard-Earned Money, and Stay Out of Court43.” This article can be accessed online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558790/pdf/icns_12_7-8_34.pdf. Read this article. Select at least 5 charting practices identified in this article that pose risk for fraudulent or harmful medical documentation.

a. Spelling Errors

b. Grammatical Errors

c. Use of templates

d. Pre-populating fields

e. Using default data

f. Documenting by exception

g. Documenting by inclusion

h. Using “box checking” in the EHR

i. Using “drop boxes” in the EHR

j. Information overload

k. Amending data

l. Using “decision-support tools” in the EHR

m. Overreliance on information entered into the medical record by other staff members

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17. Which of the following actions can you take to ensure that your own medical documentation services enhance – rather than compromise – the quality of care your provider is able to deliver to his/her patients in light of Donna Vanderpool’s 2015 article “EHR Documentation: How to Keep Your Patients Safe, Keep Your Hard-Earned Money, and Stay Out of Court.” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558790/pdf/icns_12_7-8_34.pdf)?

a. Scribe all medical record documentation on paper by hand before entering any information into the electronic health record.

b. Avoid using shortcuts in the EHR

c. Use templates with caution

d. Use templates as documentation prompts rather than documentation scripts

e. Verify all pre-populated information for accuracy

f. Ensure that you know what data is documented by default (auto-populated) if you do not enter data in a field

g. Avoid using “box checking” and “drop-down” documentation tools when documenting in the EHR

h. Be discerning in the information you choose to include or allow into a patient’s medical record

i. Understand your healthcare facilities policies regarding amending data

j. Avoid using “decision-support tools” in the EHR

k. Avoid relying on data obtained by other individuals. Stick to documenting data obtained during the patient-physician encounter.

l. Save copies of all records you document to take home with you for review after the end of your shift.

Questions 18 – 22: Do the following sections of a patient’s medical record contain subjective or objective information?

18. Chief Complaint (CC):

19. History of Present Illness (HPI):

20. Past, Family, and Social History (PFSH):

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21. Review of symptoms by body system (ROS):

22. Physical Examination (PE):

23. While in the patient room, the patient reports having a fever; what part(s) of the medical record would you document this information in? Select all that apply.

a. History of Present Illness

b. Review of Systems

c. Past, Family, and Social History

d. Physical Examination

24. While conducting the physical examination, the patient reports having a fever; however, the patient’s vital signs reveal that the patient is afebrile. Select which response below you would document in each portion of the patient’s chart.

a. History of Present Illness: Patient reports having a fever

b. History of Present Illness: Patient is afebrile

c. Review of Systems: Patient reports having a fever

d. Review of Systems: Patient is afebrile

e. Physical Examination: Patient reports having a fever

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1. You are scheduled to work an 8am shift with Dr. Smith. What time will you set your alarm to wake up? How will you prepare for this shift? (See Assessment #2 for greater guidance in completing this task).

2. You have not worked with Dr. Smith before. How will you prepare for your first shift?

3. You know you are supposed to take initiative by introducing yourself to Dr. Smith as his or her scribe; how will you identify who Dr. Smith is?

4. Why is it important to arrive early to each shift?

5. What are 4 actions you will take after arriving early to a facility, but prior to seeing your first patient with the provider?

i. ____________________________

ii. ____________________________

iii. ____________________________

iv. ____________________________

6. 6A. What is “pre-charting” and why is it important?

6B. What are three limitations or risks involved in “pre-charting?”

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6C. How will you avoid these risks in your role as an independent clinical scribe?

7. 7A. In 2015, Donna Vanderpool, MPA, JD, published an article on the regulatory risks of electronic medial documentation titled: “EHR Documentation: How to Keep Your Patients Safe, Keep Your Hard-Earned Money, and Stay Out of Court43.” This article can be accessed online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558790/pdf/icns_12_7-8_34.pdf. Read this article. What are 5 charting practices identified in this article that pose risk for fraudulent or harmful medical documentation?

7B. What are 5 actions you can take to ensure that your own medical documentation services enhance – rather than compromise – the quality of care your provider is able to deliver to his/her patients in light of this article?

8. While the provider is interacting with the patient, the scribe documents pertinent information from the patient-provider interaction. The information a scribe obtains and documents during the initial patient encounter corresponds with 5 sections of a patient’s chart. What are these 5 categories of information?

HINT: Each category has an acronym that is provided in parentheses throughout the CSAT manual and course; 4 of the 5 categories are subjective information and may be obtained prior to the patient-provider encounter. The 5th category of information is objective and obtained only by the provider.

a. ____________________________

b. ____________________________

c. ____________________________

d. ____________________________

e. ____________________________

9. Which of the 5 categories contain subjective information and which of these categories contain objective information?

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10. Besides the information identified above, what other information will be discussed and documented during the initial patient-provider encounter? HINT: this information would be documented in the “Assessment & Plan” portion of the cart:

11. While in the patient room, the provider tells you to document that “reflexes are 2/4 bilaterally.” What does this mean and where would you document this in the chart?

12. How would you respond to the above scenario if you were unsure of what the provider has asked you to document, or if you are unsure of where to document this information in the medical record?

13. You see one of your patients show up on the schedule. What does this mean, and how do you respond?

14. After alerting your provider that your next patient has arrived, the provider asks how long the patient has been waiting. How will you find this information?

15. Your shift is scheduled to end at 4p. It is currently 3:50p and your provider decides to take a walk-in patient. You have a night class at 5:00p that you cannot be late for, so staying late is not an option for you. How would you respond?SAMPLE

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Chapter 5: Industry Regulations (HIPAA & HITECH)

50

5Industry Regulations (HIPAA & HITECH)

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Chapter 5 Review

1. The Health Insurance Portability and Accountability Act (HIPAA), passed in 1996, was the first set of national standards passed to protect the privacy and security of individually identifiable health information. HIPAA is comprised of two rules:

h The HIPAA Privacy Rule, which addresses the use and disclosure of all Protected Health Information (PHI)

h The HIPAA Security Rule, which protects PHI transmitted or stored electronically.

2. The HIPAA Privacy Rule provides national standards for protecting individually identifiable health information and applies to four entities: health plans, healthcare providers, healthcare clearinghouses, and business associates44.

3. HIPAA applies to statutorily defined Covered Entities and Business Associates.

h Covered Entities include health plans, health care providers, or health care clearinghouses

h Business Associates entail persons or entities which process or access PHI on behalf of a covered entity.

4. ScribeConnect is a scribe service provider. We provide a service on behalf of health care providers; thus, we are considered a Business Associate and we are subject to the HIPAA Privacy rule

5. PHI includes any information, including demographic data, that relates to:

h Past, present, or future physical or mental health or condition of the individual

h Provisions of health care to the individual

h Past, present, or future payment for the provision of health care to the individual

6. In order to constitute Protected Health Information (PHI), patient information must have both of the following two elements:

h Information relating to the condition/treatment/payment for treatment of the patient

h A patient identifier (such as name, DOB, date of treatment, etc.).

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8. Provide 4 examples of PHI that you will have access to as a scribe:

i. ____________________________

ii. ____________________________

iii. ____________________________

iv. ____________________________

9. What are the only two permissible circumstances to use or disclose PHI?

10. What are the top 5 things you plan to do (or not do) in order to ensure compliance with HIPAA?

i. ____________________________

ii. ____________________________

iii. ____________________________

iv. ____________________________

v. ____________________________

11. In the event that a provider or other staff member asks you to take an action that would violate HIPAA, how would you personally respond?

12. Explain what the “Minimum Necessary” Rule means:

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Module I: Refefrences

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Module I References

1. Commission TJ. Documentation Assistance Provided by Scribes: What guidelines should be followed when physicians or other licensed independent practitioners use scribes to assist with documentation? Perspectives® Newsletter: The Official Newsletter of The Joint Commission. 2018;38(8).

2. Woodcock DV, Pranaat R, McGrath K, Ash JS. The Evolving Role of Medical Scribe: Variation and Implications for Organizational Effectiveness and Safety. Studies in health technology and informatics. 2017;234:382-388.

3. Martel ML, Imdieke BH, Holm KM, et al. Developing a Medical Scribe Program at an Academic Hospital: The Hennepin County Medical Center Experience. Joint Commission journal on quality and patient safety / Joint Commission Resources. 2018;44(5):238-249.

4. Chapman SA, Blash LK. New Roles for Medical Assistants in Innovative Primary Care Practices. Health services research. 2017;52 Suppl 1:383-406.

5. Yan C, Rose S, Rothberg MB, Mercer MB, Goodman K, Misra-Hebert AD. Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care. J Gen Intern Med. 2016;31(9):990-995.

6. Hawkinson N. Integration of Medical Scribes. The Journal of medical practice management: MPM. 2015;31(3):147-149.

7. Bryant H. Board’s eye view - Role of the scribe. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association. 2015;23(7):15.

8. Menon SP. Maximizing Time with the Patient: the Creative Concept of a Physician Scribe. Current oncology reports. 2015;17(12):59.

9. ScribeConnect’s 4th Annual Leadership Advancement Conference. Idyllwild, CA.: ScribeConnect, LLC; May, 2018.

10. ScribeConnect L. ScribeConnect’s Scribe Training Course (STC) Manual, 4th Edition. 4 ed2014.

11. ScribeConnect L. ScribeConnect’s Intensive Training Program (ITP) Student Manual, 4th Edition. 4 ed. Idyllwild, CA: ScribeConnect, LLC; 2014.

Module I References

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48. OCR OoCR. HITECH Act Enforcement Interim Final Rule. HIPAA For Professionals 2017; https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html. Accessed Jan 21, 2019, 2019.

49. Gold M, Mc LC. Assessing HITECH Implementation and Lessons: 5 Years Later. The Milbank quarterly. 2016;94(3):654-687.

50. Cohen MF. Impact of the HITECH financial incentives on EHR adoption in small, physician-owned practices. Int J Med Inform. 2016;94:143-154.

51. DHHS USDoHaHS. Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules In: Services USDoHaH, ed. Vol 78. Fedderal Register: Federal Register; 2013:5566-5702.

52. DHHS USDoHaHS. HIPAA Administrative Simplification: Enforcement. In: Services USDoHaH, ed. Vol 74. 45 CFR Part 160; RIN 0991–AB55 ed. Federal Register: Federal Regiser; 2009:56123-56131.

53. (CMS) CfMMS, (MLN) MLN, (DHHS) USDoHaHS. Evaluation and Management Services Guide. In: Network DoHaHSCfMMSML, ed. Vol ICN: 006764. http://www.cms.gov/ Center for Medicare & Medicaid Services (CMS); 2017.

54. CMS CfMMS. 1997 Documentation Guidelines for Evaluation and Management Services. In: Services CfMM, ed. http://www.cms.gov/ Centers for Medicare & Medicaid Services; 1997.

55. CMS CfMMS. 1995 Documentation Guidelines for Evaluation and Management Services. In: (CMS) CfMMS, ed. http://www.cms.gov/ Centers for Medicare & Medicaid Services; 1995.

56. Asbell RL. Scribing, Signatures, and Attestations. Retina Today. 2015;May/June.

57. CMS CfMMS. Signature Guidelines for Medical Review Purposes - JA6698. In: Centers for Medicare & Medicaid Services (CMS) USDoHaHS, ed. Vol JA6698. http://www.cms.gov/ Centers for Medicare & Medicaid Services; Medicare Learning Network; 2010.

58. Chapter 1 title image: Freepik.com. Used by permission. Accessed July 29, 2019.

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https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule

https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule

http://www.cms.gov/

http://www.cms.gov/

http://www.cms.gov/

Chapter 6. The Provider SOAP Note

Chapter 7. Example Provider Note

Chapter 8. General Medical Terminology and Pathology

Chapter 9. Diagnostic Laboratory Studies

Chapter 10. Diagnostic Imaging Studies

Chapter 11. Medical Procedures

Module II:Medical Documentation

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Module II - Table of Contents – In Detail

Chapter 6: The Provider SOAP Note ...................................................................................................... 74

The Provider SOAP Note .................................................................................................................... 75Recommended Resources .................................................................................................................. 75Review ...................................................................................................................................................... 77Assessment #1 (35 Questions) ........................................................................................................ 81Assessment #2 (29 Questions) ........................................................................................................ 90Final Assessment (21 Questions) .................................................................................................... 99

Chapter 7: Example Provider Note ...........................................................................................102

Example Provider Note ...................................................................................................................... 103Example Provider Note ...................................................................................................................... 103Recommended Resources .................................................................................................................. 105Assessment (7 Questions) .................................................................................................................. 107

Chapter 8: Medical Terminology & Pathology ........................................................................110

Medical Terminology & Pathology ................................................................................................. 111Recommended Resources .................................................................................................................. 111Review ...................................................................................................................................................... 112Independent Assessment (No Answer Key) ................................................................................. 112Assessment #1 (65 Questions, with Answer Key) ..................................................................... 127Assessment #2 (63 Questions, with Answer Key) ..................................................................... 132Assessment #3 (57 Questions, with Answer Key) ..................................................................... 138Assessment #4 (60 Questions, with Answer Key) ..................................................................... 144Assessment #5 (45 Questions, with Answer Key) ..................................................................... 149Assessment #6 (45 Questions, with Answer Key) ..................................................................... 155Final Assessment (24 Questions, with Answer Key) ................................................................ 165

Chapter 9: Diagnostic Laboratory Studies ...............................................................................170

Diagnostic Laboratory Studies ......................................................................................................... 171Recommended Resources .................................................................................................................. 171Review ...................................................................................................................................................... 172Assessment #1 (35 Questions) ........................................................................................................ 176Assessment #2 (55 Questions) ........................................................................................................ 177Assessment #3 (65 Questions) ........................................................................................................ 189Final Assessment (50 Questions) .................................................................................................... 203

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Chapter 10: Diagnostic Imaging Studies .................................................................................209

Diagnostic Imaging Studies .............................................................................................................. 210Recommended Resources .................................................................................................................. 210Review ...................................................................................................................................................... 211Assessment (45 Questions) ............................................................................................................... 216Final Assessment (25 Questions) .................................................................................................... 233

Chapter 11: Medical Procedures ..............................................................................................236

Medical Procedures ............................................................................................................................. 237Recommended Resources .................................................................................................................. 237Review ...................................................................................................................................................... 238Assessment # 1 (26 Questions) ....................................................................................................... 243Assessment # 2 (26 Questions) ....................................................................................................... 252Final Assessment (23 Questions) .................................................................................................... 255

References Module II .................................................................................................................257

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Chapter 6: The Provider SOAP Note

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6The Provider SOAP Note

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1. What part of the physician’s chart is the Assessment and Plan?

a. HPI

b. PFSH

c. ROS

d. PE

e. MDM

2. What is the section of the chart called that comprises the ‘laundry list’ of complaints that patient has?

a. Medical Decision Making

b. Differential Diagnoses

c. Physical Exam

d. Review of Systems

e. All of the above may contain these complaints

3. The DDx and Dx will be documented in the _______________ area of the chart.

a. Assessment

b. Procedures

c. Disposition

d. Plan

e. None of the above

4. While evaluating a patient who presented with a complaint of abdominal cramping, your physician tells you that the bowel sounds are normal. You would document this in the:

a. HPI

b. ROS

c. PFSH

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Chapter 6 Final Assessment (21 Questions)

1. List the four parts of the SOAP note:

i. ______________________

ii. ______________________

iii. ______________________

iv. ______________________

2. What is an HPI?

3. How does an HPI differ from a CC?

4. Identify 5 important elements of an HPI?

5. This chapter identified several pneumonic devices that can be used to remember important elements that should be documented in a patient’s HPI: identify one of these acronyms that you might use on the floor:

6. What are the three components of “patient histories” that are charting requirements for reimbursement by Centers for Medicare and Medicaid Services (CMS)?

7. Thinking Ahead: What is CMS, and why might CMS be relevant to you as a scribe?

8. A patient tells the provider she used to smoke cigarettes but quit smoking 3 weeks ago. What part of the provider note would you document this information in? Is this information subjective or objective?

9. Your provider does not ask a patient about his or her social history in the room; however, you notice the patient is wearing a wedding ring and has a child; can you document in the Social History that the patient is married with a child? Why or why not?

10. 10A. The physician instructs you to document on the patient’s physical exam that the patient “smells of tobacco.” You notice that the patient’s smoking status is not identified in his social history; can you update this information in his electronic medical record (EMR)? Why or why not, and how would you make this decision?

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Chapter 7: Example Provider Note

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7Example Provider Note

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Chapter 8: Medical Terminology & Pathology

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8Medical Terminology & Pathology

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Chapter 8 Assessment #1 (65 Questions, with Answer Key)

Questions 1 – 9: Use the “DEFINITIONS” word bank below to the match the Review of Systems (ROS) terms with the appropriate definitions.

1. Constitutional:

2. HEENT:

3. Photophobia:

4. Tinnitus:

5. GI:

6. Incontinence:

7. Vertigo:

8. Paresthesia:

9. Ataxia:

DEFINITIONS WORD BANK FOR QUESTIONS 1 - 9:

a. “Dizziness” described as a sensation of lightheadedness:

b. “Dizziness” described as sensation of the room spinning:

c. Abnormal and irritable constitution or demeanor:

d. Abnormal dermal (skin) sensation (such as tingling, pricking, chilling, burning, or numbness):

e. Degenerative disease of the nervous system causing loss of control over balance and movement coordination. May also be used to describe loss of control over balance and movement coordination without a diagnosis of any neurologic degeneration:

f. Gastrointestinal:

g. Genitourinary:

h. Hardening of the skin:

i. Head, Eyes, Ears, Nose, Throat:

j. Inability to formulate words:

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QUESTIONS 43 - 65: Identify the appropriate terms and definitions.

Medical Term DefinitionHematemesis

Yellow discoloration of the skin, typically associated with a liver disorderDyspepsiaAuscultationProneMyalgiaPurulentParacentesis

Loss of coordinationGeneral term for pain with breathing

OcclusionAbnormal tactile sensation often described as tingling, numbness, or pinpricking

Peritoneal SignsMelenaPronator DriftNormocephalic

Protrusion of an organ through the wall within which it is normally contained

PruriticNystagmus

Inflammation of the pancreasMelanomaOtitis MediaPVCs SAMPLE

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QUESTIONS 1 – 11: Match the medical term with the definition (1 point each)

1. Rigidity

2. Palpitation

3. Ecchymosis

4. Erythema

5. Adenopathy

6. Tinnitus

7. Diplopia

8. Hepatomegaly

9. Paresthesia

10. Cyanosis

11. Jaundice

12. What is CAD an acronym for?

a. Carotid Artery Disease

b. Coronary Artery Disease

c. Cardiac Artery Disease

d. Cerebral Atrophy Deficit


A. Redness

B. Ringing in the ears

C. Double vision

D. Blue color

E. Bruising

F. Yellow skin

G. Tingling/numbness sensation

H. To touch/feel

I. Abdominal muscle stiffness

J. Enlarged lymph nodes

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1. While evaluating a patient who presented with a complaint of abdominal cramping, your physician tells you that the bowel sounds are normal. You would document this in the:

a. HPI

b. ROS

c. PFSH

d. EXAM

e. MDM

2. A 23 year old female is being seen for a routine pregnancy checkup. She is 30 weeks along and the fetal heart tones are 135 and normal. Where would you document the fetal heart tones?

a. HPI

b. ROS

c. PFSH

d. EXAM

e. MDM

3. A 46 year old male is being seen for a metal splinter in his eye. His father has known history of CAD. You would document his father’s condition in the:

a. HPI

b. ROS

c. PFSH

d. EXAM

e. MDM

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WORD BANK FOR QUESTION 21:

Epigastric Region/Epigastrium

Left Lower Quadrant (LLQ)

Left Upper Quadrant (LUQ)

Periumbilical Region

Right Lower Quadrant (RLQ)

Right Upper Quadrant (RUQ)

Suprapubic Region

a. _________________________________

b. _________________________________

c. _________________________________

d. _________________________________

e. _________________________________

f. _________________________________

g. _________________________________

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Chapter 9: Diagnostic Laboratory Studies

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9Diagnostic Laboratory Studies

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1. This protein complex is found in skeletal and cardiac tissues and is integral to muscle contraction. Blood levels may be used as diagnostic indicators of muscle damage, as occurs after myocardial infarction (MI, “heart attack”) and in acute coronary artery disease (CAD). However, blood levels are usually not detectable until 3 hours after cardiac muscle damage has occurred. Blood troponin levels can also become elevated after muscular exertion.

2. This enzyme is found in heart, brain, and skeletal muscle tissue and is released into the blood during muscle tissue damage. Elevated levels of this enzyme – or a specific form of this enzyme – in the blood can indicate myocardial tissue damage that occurs during acute myocardial infarction (MI, “heart attack”). Of note: many facilities may prefer to test blood levels of a cardiac protein complex rather than using this test for ruling in or out an MI.

3. Which of the following studies are useful in ruling in- or out a myocardial infarction? Select all that apply.

a. CK-MB

b. CRP

c. D-Dimer

d. PT-INR

e. Sed Rate

f. Troponin

4. Which of the following studies are useful in ruling out CHF:

a. ABG & VBG

b. BNP

c. CK-MB

d. CRP

e. D-Dimer

f. Pt-INR

g. Troponin

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Chapter 10: Diagnostic Imaging Studies

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10Diagnostic Imaging Studies

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45. What is the BEST diagnostic tool for pneumonia?

a. CBC

b. Chest x-ray

c. Chest ultrasound

d. PET scan



1. Create a Review Outline for the various imaging studies identified in this chapter (similar to the Review Outline provided in the Independent Assessment section of Chapter 8). You may want to create this Review Outline on a notecard that you can keep in your pocket to refer to during your clinical training and CSAT Phase IV independent evaluation period.

2. Review the outlines you created in chapter 8. As you review the different complaints and diagnoses try to identify what types of imaging studies may commonly be associated with various chief complaints and differential diagnoses. You will be held responsible for familiarizing yourself with these imaging studies and their indications as part of your CSAT assessment.

For questions 3 – 17, define the following acronyms:

3. US:

4. KUB US:

5. OB US:

6. XR:

7. CXR:

8. CXR-Pt:

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11Medical Procedures

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1. Create a Review Outline for the various procedures identified in this chapter (similar to the Review Outline provided in the Independent Assessment section in Chapter 8). You may want to create this Review Outline on a notecard that you can keep in your pocket to refer to during your clinical training and Stage IV independent evaluation period.

2. Review the outlines you completed in chapter 8. As you review the different complaints and diagnoses try to identify what types of laboratory studies may commonly be associated with various chief complaints and differential diagnoses. You will be held responsible for familiarizing yourself with these lab studies and their indications as part of your CSAT assessment.

For questions 3 – 9: Define the following acronyms:

3. CPR:

4. CSF:

5. HD:

6. I&D:

7. Lac Repair:

8. LP:

9. Spinal Tap:

10. What six procedures covered in this chapter may be used as diagnostic tools to advance patient care?

11. What are 14 documentation components that should be documented in all procedure notes?

12. What is a universal surgical time-out?

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Chapter 12. Healthcare Industry: Historical Overview

Chapter 13. MACRA & QPPs

Chapter 14. E/M Coding: ICD, HCPCS, & CPT

Chapter 15. E/M Coding in Depth

Chapter 16. The Scribe Role in Medical Coding

Module III:Coding, Billing, & Reimbursement

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Module III - Table of Contents – In Detail

Chapter 12: Healthcare Industry: Historical Overview ..........................................................262

A Historical Overview of the Healthcare Industry Landscape .............................................. 263Recommended Resources .................................................................................................................. 263Review ...................................................................................................................................................... 264

Review I: Evaluation and Management (E/M) Terms for the Clinical Scribe ............................. 264Review II: Legislative Standards that affect the Clinical Scribe ................................. 266Review III: CMS Programs that affect the Clinical Scribe ............................................. 266

Review IV: MACRA & QPPs ................................................................................................................ 268Assessment # 1 (59 Questions) ....................................................................................................... 270Final Assessment (18 Questions) .................................................................................................... 282

Chapter 13: MACRA & QPPs .....................................................................................................284

The Medicare and CHIP Reauthorization Act of 2015 (MACRA) & the Quality Payment Program (QPP) ....................................................................................................................................... 285Recommended Resources .................................................................................................................. 285General Review ...................................................................................................................................... 287In Depth Review of MACRA & QPPs ............................................................................................... 289In Depth Review of MIPS Scoring for Reimbursement ............................................................ 291In Depth Review of MIPS Pillar 1: Quality of Care (PQRS) ..................................................... 292SuperScribe Applications: .................................................................................................................. 294In Depth Review of MIPS Pillar 2: Promoting Interoperability (PI) ..................................... 296SuperScribe Applications: .................................................................................................................. 297In Depth Review of MIPS Pillar 3: Improvement Activities (IA) ........................................... 298SuperScribe Applications: .................................................................................................................. 300In Depth Review of MIPS Pillar 4: Cost ......................................................................................... 303In Depth Review of AMPs: Alternative Payment Models ........................................................ 304In Depth Review of MIPS-APMs ...................................................................................................... 305In Depth Review of Advanced APMs (AAPMs) ............................................................................ 306In Depth Review of Other APMs ...................................................................................................... 307Assessment #1 (16 Questions) ........................................................................................................ 308Assessment #2 (46 Questions) ........................................................................................................ 309Final Assessment (10 Questions) .................................................................................................... 324

Chapter 14: E/M Coding: ICD, HCPCS, & CPT ..........................................................................325

Introduction to E/M Coding: ICD, HCPCS, & CPT ....................................................................... 326Recommended Resources .................................................................................................................. 326General Review ...................................................................................................................................... 328

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In Depth Review of E/M Coding Levels (1 – 5) ........................................................................... 330In Depth Review of E/M Coding: ICD and HCPCS CPT Code Sets ........................................ 331Assessment #1 (25 Questions) ........................................................................................................ 334Assessment #2 (25 Questions) ........................................................................................................ 341Final Assessment (18 Questions) .................................................................................................... 352

Chapter 15: E/M Coding in Depth ............................................................................................358

E/M Coding in Depth ........................................................................................................................... 359Recommended Resources .................................................................................................................. 359General Review ...................................................................................................................................... 361SuperScribe Tips for overall E/M Documentation .................................................................... 365

History ............................................................................................................................................. 366Examination .................................................................................................................................. 367MDM Complexity ......................................................................................................................... 367Coordination of Care .................................................................................................................. 370

Assessment #1 (29 Questions) ........................................................................................................ 372Assessment #2 (32 Questions) ........................................................................................................ 381Assessment #3 (27 Questions) ......................................................................................................... 389Assessment #4 (29 Questions) ........................................................................................................ 397Assessment #5 (23 Questions) ........................................................................................................ 407Final Assessment (16 Questions) .................................................................................................... 414

Chapter 16: The Scribe Role in Medical Coding .....................................................................417

Putting It All Together: The Scribe Role in Medical Coding .................................................. 418Recommended Resources .................................................................................................................. 418Review ...................................................................................................................................................... 420Assessment #1 (31 Questions) ........................................................................................................ 421Final Assessment (3 Questions) ...................................................................................................... 433

References Module III: ...............................................................................................................434

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12Healthcare Industry: Historical Overview

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Chapter 12 Review II: Legislative Standards that affect the Clinical Scribe

The Health Insurance Portability and Accountability Act (HIPAA)15,24,25 was enacted in 1996 to increase American health insurance coverage and health care provisions15,24-26. A large portion of HIPAA focuses on protecting patient rights in an effort to combat insurance fraud26. This aim lead to the HIPAA Privacy-, Security-, and Enforcement Rules outlined in Chapter 5 of Module I. HIPAA also mandated use of the HCFA’s Common Procedural Coding Set (HCPCS) for all transactions involving health care information, as outlined above and in Chapter 148,11,14,15.

The Health Information Technology Economic and Clinical Health (HITECH) Act was passed in 2009 under the American Recovery and Reinvestment Act (ARRA) to promote Health Information Technology (HIT) adoption and meaningful use26-31. HITECH promoted standardized regulations for certified health information technology (CHIT) and provided “substantial resources” to offset the cost of adopting and using EHRs for eligible hospitals and providers.

Certified Health Information Technology (CHIT, CEHIT) refers to electronic health record technology that has been certified by the Office of the National Coordinator for Health Information Technology (ONCHIT) and meets “core functions” for meaningful use of HIT and EHR systems, according to the National Academy of Medicine (NAM) 2003 standards26,32,33.

Chapter 12 Review III: CMS Programs that affect the Clinical Scribe

The Centers for Medicare & Medicaid Services (CMS) is an agency within the U.S. Department of Health & Human Services responsible for administering several important health care programs and initiatives34. The healthcare industry receives a large portion of its funding from CMS through these programs. Common CMS programs and initiatives include:

h Medicare: A federally funded program that provides health insurance to Americans over the age of 65 years old, and to younger Americans with disabilities or with End-Stage Renal Disease (ESRD, permanent kidney failure requiring dialysis or a transplant)35,36.

h Medicaid: A program funded by both the federal and state governments for families and individuals with low income or resources37,38. Medicaid is one of the largest payers for health care in the United States38.

h Children’s Health Insurance Program (CHIP): A program designed to cover uninsured children in families with low incomes, but that are not low enough to qualify for Medicaid39,40.

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1. What is E/M Coding, and how might it be relevant to your role as a Clinical Scribe?

2. What are CPT and ICD-10? How do are similar to- and different from one another?

3. What information might you need to know about CPT and ICD-10 codes to excel in your role as a Clinical Scribe? How might you find this information?

4. What are Clinical Quality Measures (CQMs) and how are they similar to- or different from Physician Quality Reporting System (PQRS) measures?

5. How do MACRA, QPP, MIPS, and APP all relate to one another?

6. What are PQRS and Meaningful Use?

7. How do PQRS and Meaningful Use relate to MACRA’s MIPS program?

8. How might PQRS and Meaningful Use relate to you as a Clinical Scribe?

9. What is HCC Coding?

10. True or False: Each diagnosis you enter into a patient’s medical record will be associated with a specific ICD-10 code. The ICD-10 code may then be used by a professional coder to determine a patient’s risk adjustment factor (RAF) score, which is used to determine a patient’s insurance costs in turns.

11. Does your facility use Hierarchical Condition Category (HCC) coding? If you are unsure, how might you go about finding out?

12. Which of the following statements are true of MACRA’s Quality Payment Program (QPP), which went into effect in 2017? Select all that apply.

a. MACRA’s QPP streamlined multiple old quality programs (CMS’ EHR “Meaningful Use” Incentive Programs and PQRS) into a new Merit-Based Incentive Payment System (MIPS).

b. MACRA’s QPP created a new system for the way that Medicare rewards clinicians for “value over volume.”

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13MACRA & QPPs

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h Cost

• Replaces CMS’ old Value-Based Modifier Program (VBM or VM)

• Emphasizes the value – rather than volume – of patient care3

• CMS uses Medicare claims data to calculate the cost of care provided to Medicare patients in relation to the resources clinicians use to care for Medicare patients1

Like PQRS, MU, and VBM, each of the Four MIPS Pillars include specific reporting requirements, and are used by CMS to determine how providers receive MACRA provisions and Medicare payment. Requirements of each of these four pillars are addressed further below.

Chapter 13 In Depth Review of MIPS Scoring for Reimbursement

Providers who participate in MIPS receive Incentive Payments from Medicare for the 2 years following the Fiscal Year in which they enroll and participate in a MIPS program. The amount of monetary Incentive Payments a provider receives from CMS through MIPS is calculated by CMS using a MIPS Score, which can range of 0 (failure to report any measures) to 100 (the maximum score, indicating complete MIPS compliance).

MIPS Providers can also earn bonus points (such as through reporting all data using a CEHRT) that can further enhance their score. MIPS Scoring is weighted, so providers receive scores in each of the Four MIPS pillars, and each of the four pillars holds a different weight in terms of a provider’s overall score.

As of 2019, the weights associated with each of the four MIPS Pillars are as follows:

h Quality: 45%47

h Promoting Interoperability (PI): 25%63

h Improvement Activities (IA): 15%64

h Cost: 15%1

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PI Measures – Health Information Exchange:

h Support Electronic Referral Loops by:

• Required: Receiving and Incorporating Health Information (≤20% Score Weight)

• Required: Sending Health Information (≤20% Score Weight)

PI Measures – Provider-Patient Exchange:

h Required: Provide patients with electronic access to their health information (≤40%)

PI Measures – Public Health and Clinical Data Exchange:

h Required: Clinical Data Registry Reporting (0% Score Weight)

h Required: Electronic Case Reporting (0% Score Weight)

h Required: Immunization Registry Reporting (0% Score Weight)

h Required: Public Health Registry Reporting (0% Score Weight)

h Required: Syndromic Surveillance Reporting (0% Score Weight)

MIPS Participants are also required to comply with the following PI measures63:

h Attest that HIT has not been tampered with or blocked

h Agree to cooperation with ONC Direct Review of CEHRT

h Conduct a security risk analysis in accordance with HIPAA Privacy and Security Rules

Chapter 13 In Depth Review of MIPS Pillar 3: Improvement Activities (IA)

MIPS’ third pillar – Improvement Activities (IA) – is a new performance category (as of 2017) that incorporates some Clinical Quality Measures (CQM), parts of CMS’ Patient Quality Reporting System (PQRS), and Medicare’s Meaningful Use (MU) Incentive Program to maintain a focus on how a provider improves patient care processes, engagement, and access to care3. This is done through completion of an activity assessment inventory that allows providers to choose which activities they would like to focus on and receive assessment in. These activities include enhancing patient care coordination, patient and clinician shared decision-making, and expansion of practice access3.

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1. What are the Four MIPS Pillars?

2. What old quality programs are now rolled into the Four MIPS Pillars?

3. What are PQRS and Meaningful Use?

4. How do MACRA, QPP, MIPS, and APP all relate to one another?

5. How do PQRS and Meaningful Use relate to MACRA’s MIPS program? What MIPS Pillars to PQRS and Meaningful Use map onto?

6. Is your provider or hospital enrolled in MIPS or an APM? If you do not know the answer to this question, how can you find out?

7. What measures and activities have your provider(s) or facility chosen to report on to meet QPP Eligibility Requirements? If you do not know the answer to this question, how can you find out?

8. How can you help your provider or hospital meet the QPP Standards for each of the Four MIPS Pillars?

9. Are PQRS and Meaningful Use still relevant to you as a Clinical Scribe? Why or why not, and How?

10. Identify 6 Quality Measures, 9 Promoting Interoperability Measures, and 4 Improvement Activities that you could help a provider meet in your role as a Clinical Scribe. How could you help your provider meet these Measures/Activities?SAMPLE

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14E/M Coding: ICD, HCPCS, & CPT

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3. CMS’ National Coverage Determinations (NCDs) Alphabetical Index (2019):

h https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx

h Provides information on indications and limitations of coverage for all medical items and services that are nationally eligible for Medicare compensation.

Introduction to E/M Coding: ICD, HCPCS, & CPT

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4. CMS’ Lab National Coverage Determinations (NCDs) Index (2019):

h https://www.cms.gov/medicare-coverage-database/indexes/lab-ncd-index.aspx

h Provides information on indications and limitations of coverage for all laboratory studies that are nationally eligible for Medicare compensation.

5. CMS’ Local Coverage Determinations (LCDs) by State Index (2019):

h https://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx

h Provides information on regional indications and limitations of coverage for all medical items and services that are eligible for Medicare compensation regionally.

h Local Coverage Determinations (LCDs) Index also available by contractor: https://www.cms.gov/medicare-coverage-database/indexes/lcd-contractor-index.aspx.

6. CMS’ 2017 E/M Services Guide:

h CMS: Center for Medicare & Medicaid Services. Evaluation and Management Services Guide. Medicare Learning Network (MLN); U.S. Department of Health and Human Services (DHHS), ed. ICN: 006764. http://www.cms.gov/ Center for Medicare & Medicaid Services (CMS); 20177.

h Most up to date E/M Service Guidelines for coding and billing

h Includes 1997 and 1995 Guidelines

h https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

7. Heidelbaugh JJ, Riley M, Habetler JM. 10 billing & coding tips to boost your reimbursement. The Journal of family practice. 2008;57(11):724-730.

h Reviews documentation requirements for higher-level visits (Tables 1 and 2) and provides suggestions for encounter templates.

– Table 1 shows CPT codes and documentation requirements for established patients for 5 different E/M Codes: 99211; 99212; 99213; 99214; 99215.

– Table 2 shows CPT codes and documentation requirements for new patients for 5 different E/M code levels: 99201; 99202; 99203; 99204; 99205.

h Provides 10 coding, billing, and documentation suggestions for maximizing reimbursement.

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h Available online at:

– https: //www.mdedge.com/familymedicine/ar ticle/63368/practice-management/10-billing-coding-tips-boost-your-reimbursement

– https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/5711JFP_Article2.pdf

Chapter 14 General Review

1. Medical Necessity refers to the medical reason or necessity for which an item or service is administered; this must be clearly addressed in a patient’s chart for the service to receive insurance compensation7,9,84,85.

2. The Evaluation and Management (E/M) Coding system constitutes the standardized coding and billing system used by practicing providers and health care providers in the U.S. to receive reimbursement by the Centers for Medicare & Medicaid Services (CMS), and by most private insurance companies for services rendered during patient encounters7,86,87.

3. The E/M coding system is based upon two coding systems and sets:

h The 10th Revision of the International Classification of Diseases – Clinical Modification (ICD-10-CM), used for identifying diagnoses

h The Healthcare Common Procedural Coding System (HCPCS, “HICK PICKS”), used for identifying medical and surgical services, procedures, and furnishings, and which includes two levels of codes7,8,11,14:

i. The Current Procedural Terminology (CPT) Coding Set (Level I) for medical and surgical services and procedures furnished by a practitioner

ii. The Level II Non-CPT Code Set for products, supplies, and non-physician services.

4. International Classification of Diseases 10th Revision – Clinical Modification (ICD-10-CM): The diagnosis classification system developed by the World Health Organization and adapted by the Centers for Disease Control and Prevention for use in all U.S. healthcare treatment settings. ICD-10-CM was formally adopted for use in the U.S. on Oct. 1, 201517,19.

h Diagnosis coding under the ICD-10-CM system uses 3-7 alphanumeric digits and full code titles; the format is like that of ICD-9-CM.

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Chapter 14 In Depth Review of E/M Coding Levels (1 – 5)

The seven components of the medical record that define an encounter’s overall E/M coding level are7,87:

1. History*

• Including CC, HPI, PFSH, and ROS

2. Physical Examination*

3. Medical Decision-Making*

• Including Assessment, Clinical Impression or Diagnosis, and Medical Plan of Care

4. Counseling

5. Coordination of Care

6. Nature of Presenting Problem

7. Time

*Of these seven coding components, the first three components (history, physical examination, and medical decision-making) are the primary descriptors used to determine a medical record’s overall E/M level of service7,87. The four remaining components serve as modifying descriptors. For example, time becomes the key determining factor of overall E/M level for visits that consist primarily of counseling or coordination of care87.

Each of the seven components of the medical record (identified above) have specific coding criteria that determine that component’s level of complexity (and the E/M coding level that component will be assigned). Coding criterion within each of the seven encounter components are assessed and cumulatively used to assign each component of the medical record with its own coding level, and these component levels make up the overall E/M Coding Level of each patient encounter in turn.

Different care settings have different coding criteria for what constitutes a certain level of care (and E/M service level). Different care settings also have different numerical code sets used to specify the type of care a patient receives and the setting in which the care is provided7,88. The five numerical code levels used to code charts for patients who receive care in the various outpatient setting may be found online at:

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1. Which of the following statements are true regarding Scribe Attestations? Select all that apply.

a. CMS’ 2017 Evaluation and Management Guide instructs that medical documentation for each patient encounter include date and legible identity of observers, including provider statement of identity and signature.

b. CMS does not explicitly require documentation assistants to provide a statement of identity and signature.

c. Because clinical scribes are direct observers of the patient encounter in most cases, they are indirectly required to include a statement of identity and signature for all encounters they observe, along with the encounter date.

d. Clinical Scribes are strongly encouraged to include an attestation on each medical record that specifies the date and scribe identity.

2. Which of the following statements are true regarding Medical Necessity? Select all that apply.

a. Medicare compensation for a medical item or service requires proof that the item or service is “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” in accordance with the Social Security Act of 1935 and CMS.

b. Medicare compensation for a medical item or service requires proof that the item or service is “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless agreed upon in advance by the patient and provider.

c. The Social Security Act of 1935 states that providers may administer any medical items or services to a patient without patient consent if the item or service is “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

d. The Social Security Act of 1935 legally prohibits providers from rendering any medical items or services to a patient unless the item or service is “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

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Chapter 15 SuperScribe Tips for Documenting E/M Key Component #1: History

1. Documenting the Patient Histories:

The Chief Complaint (CC), Past Medical, Family, and Social History (PMFSH), and Review of Systems (ROS) may be documented as separate elements or included in the History of Present Illness (HPI)7,86,87. However, most EHRs have separate sections for each of these elements.

2. Documenting “All other systems were reviewed and are negative” in the Review of Systems (ROS) qualifies the ROS as Comprehensive.

3. Documentation by Ancillary Staff:

According to the CMS, ROS and/or PFSH may be documented by ancillary staff or by the patient on a form, so long as they are accompanied by a notation supplementing or confirming that the information was reviewed and verified by the medical provider7,87.

4. Document that the provider has reviewed data – such as previous PMFSH by:

h Describing new information or noting “no change.”

h Noting the date and location of previously documented PMFSH.

h Documenting: “previous patient information including PMFSH was reviewed and updated.”

5. Documenting a Limited History:

If the provider is unable to obtain a history from the patient due to the patient condition, the provider may report this and describe the way in which the patient condition limited the ability to obtain a complete patient history7,87.

h For example, infant and pediatric patients will be unable to provide a history. In these circumstances, the history will likely be obtained by a parent, and the scribe may document: “Patient history limited due to patient age. Collateral information obtained from patient parent.”

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Chapter 15 SuperScribe Tips for Documenting E/M Key Component #2: Examination

1. Document normal- and abnormal findings in the physical examination7:

h All specific abnormal and relevant negative findings must be documented and described within the affected/symptomatic OS/BA(s)

h A notation of “abnormal” without elaboration is not sufficient documentation for abnormal findings within an affected/symptomatic OS/BA.

h Abnormal or unexpected findings in asymptomatic OS/BA(s) should also be documented

h A notation of “negative” or “normal” is sufficient documentation for normal findings in unaffected/asymptomatic OS/BA(s).

Chapter 15 SuperScribe Tips for Documenting E/M Key Component #3: MDM Complexity

1. The E/M Service guidelines offer a table that can help determine “whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high7.” Risk determination is “complex and not readily quantifiable;” accordingly, the table provides “clinical examples rather than absolute measures of risk7.” We reproduced CMS’ Table of Risk (next page); the original format can be found in CMS’ 2017 Evaluation and Management Services Guide (pgs. 16 – 17) at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.

2. TJC and CMS have identified sets of cardiac and PE/DVT risk factors that should be explicitly documented in the HPI or MDM portion of the note for any patient presenting with chest pain, chest pain with shortness of breath, shortness of breath alone, or if any of the risk factors are present and pertinent.

CARDIAC RISK FACTORS:

h History (Hx) of Obesity h Hx of Coronary Artery Disease (CAD) h Hx of Diabetes Mellitus (DM) h Hx of Hypertension (HTN) h Hx of Hyperlipidemia h Hx of Tobacco Use h Family History (FHx) of CAD with onset < 55 y/o

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Questions 1 – 8: Identify the appropriate elements from the HPI below to the appropriate type of documentation element.

A patient presents complaining of 7/10 low back pain that onset 2 days ago when the patient was moving furniture. The pain is “aching,” constant, and worse with movement. The patient has tried ice, heat, and ibuprofen without relief. The patient denies any associated headaches, leg pain, neck pain or stiffness, fevers, rashes, or any numbness, tingling, or other paresthesias. The patient denies any limited ROM in the legs or arms.

1. Location:

2. Quality:

3. Severity:

4. Duration:

5. Timing:

6. Context:

7. Modifying Factors:

8. Associated Signs and Symptoms:

a. ______________________

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1. What are the 3 Key Components of a chart in relation to E/M Coding Levels? (3 points)

2. What are 3 Contributing Factors of a chart in relation to E/M Coding Levels? (3 points)

Questions #3 – 15 pertain to an established obese 55 y/o male patient who presents with a history of CAD, HTN, and DM for his annual “check-up.” The patient has not been seen in over a year, but during the encounter, he reports that he has had worsening left-sided chest pain and shortness of breath over the past month, and elevation in his home blood pressure and home blood glucose measurements. He reports that he also recently took up smoking after his father died of a heart attack 3 months ago.

NOTE: You may refer to the E/M Level Coding Chart found in Appendix A.VI, and to CMS’ Table of Risk found in CMS’ 2017 Evaluation and Management Services Guide (pgs. 16 – 17) at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide- ICN006764.pdf.

3. What level of medical decision making will most likely be involved in this patient’s encounter:

a. Minimal

b. Low

c. Moderate

d. High

4. What part of the above description suggest the level of decision making that will be required for this patient? Select all that apply.

a. The patient provides > 4 elements of information on his history of present illness.

b. The patient has ≥ chronic illnesses and has not been seen in > 1 year.

c. The patient has ≥ chronic illness with severe exacerbation/progression.

d. The patient has chest pain with cardiac risk factors.

e. The patient will require cardiovascular imaging studies with contrast with risk factors.

f. The patient will require cardiac electrophysiological testing

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Chapter 16 Review

1. As a medical scribe:

h It is not your responsibility to determine the level of workup a patient receiving care from your provider should receive; this is the provider’s responsibility.

h It is not your responsibility to determine which E/M level a chart will be coded and billed at; this is the responsibility of your facility’s coding and billing staff.

h It IS important for you to be aware of the different E/M criteria as you document each chart so that you can better help your provider ensure complete and accurate documentation and E/M coding and billing.

2. According to the Center for Medicare & Medicaid Services (CMS) 2017 Evaluation and Management (E/M) Service Guide: “If a service was documented it was not performed7.”

h The role of a Clinical Scribe is to assist the provider in ensuring all services that are performed are appropriately documented in the medical record.

3. The following suggestions are provided for clinical scribe documentation:

h DOCUMENT EVERYTHING that is PERFORMED.

h If you are unsure: ASK!

h If you don’t have enough information: ASK!

h IF YOU ARE AFRAID TO ASK: Designate a “time for questions” with your provider.

4. Additional resources that can be helpful for appropriate medical documentation and coding are available in the appendix (Appendices A.III – A.VII) and in the resources tab of the CSAT website at: www.scribeACCELERATOR.com. These include:

h Appendix A.III. Family Medicine Documentation Basics

h Provides important “How To” information for family medicine scribes

h Appendix A.IV Documentation Basics for Common Chief Complaints in Family Medicine

h Includes common orders and workup services to anticipate and important components to include in documentation to demonstrate medical necessity for most services that are likely to be ordered and rendered and meet E/M criteria.

h Appendix A.V. Documentation Basics for Preventive Measures in Family Medicine

h Appendix A.VI E/M Level Coding Criteria

h Appendix A.VII. Hierarchical Condition Category Coding and Risk Adjustment Factors (HCC and RAFs)

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1. How do the contents of this chapter apply to you as you prepare to begin your role as a Clinical Scribe? What are 5 actions you can take to help prepare for success and ensure the most thorough and accurate documentation?

2. The timeline in Chapter 12 mentions concepts of HCC and RAF. These concepts are also addressed in Appendix A.VII. What are HCC and RAF? How do they apply to you as a clinical scribe? How do they relate to E/M Coding?

3. Review Appendices A.III – A.VII.

a. What are 5 tips that you find helpful in Appendix A.III?

b. What are the common chief complaints identified in Appendix A.IV?

c. What are the Preventive Measures identified in Appendix A.V?

d. Print out the E/M Level Coding Chart (Appendix A.VI) and save this (in print or in an electronic format that is compliant with your facility’s HIPAA policies) that you can use in your role as a clinical scribe. Where will you save this? How will you use this?

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Module III References:

1. CMS CfMMS. 2019 Cost Requirements. Quality Payment Program 2019; https://qpp.cms.gov/mips/cost?py=2019. Accessed Jan 19, 2019, 2019.

2. CMS CfMMS. 2019 Cost Measures. Quality Payment Program 2019; https://qpp.cms.gov/mips/explore-measures/cost?py=2019 - measures. Accessed Feb 1, 2019, 2019.

3. MIPS Overview. Quality Payment Program (QPP) Website 2016; https://qpp.cms.gov/mips/overview. Accessed Jan 17, 2019, 2019.

4. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). In: Organization USDoHHSCfDCaPCNCfHSWH, ed. Vol Accessed Jan 10, 2019. Last Updated: Jul 26, 2018. 10 ed. Atlanta, GA: U.S. Department of Health & Human Services; 2019.

5. WHO WHO. International Classification of Diseases, 11th Revision (ICD-11). Classifications 2019; https://www.who.int/classifications/icd/en/. Accessed Jan 28, 2019, 2019.

6. WHO WHO. International Classification of Diseases (ICD) Information Sheet. Classifications: International Classification of Diseases (ICD) 2019; https://www.who.int/classifications/icd/factsheet/en/. Accessed Jan 28, 2019, 2019.


8. CMS CfMMS. HCPCS: General Information. 2018; https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html. Accessed Feb 4, 2019, 2019.

9. AAFS AAoFP. Coding for Evaluation and Management Services. Payment for Physicians 2019; https://www.aafp.org/practice-management/payment/coding/evaluation-management.html. Accessed Feb 4, 2019, 2019.

10. Guidelines for Teaching Physicians, Interns, and Residents. In: Centers for Medicare & Medicaid Services MLN, ed. Vol ICN: 006347: Centers for Medicare & Medicaid Services (CMS) & Medicare Learning Network (MLN); 2018.

11. AAFP AAoFP. Coding Basics. Medical Billing and Coding 2019; https://www.aafp.org/practice-management/payment/coding/coding-basics.html. Accessed Feb 3, 2019, 2019.

Module III References

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https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html

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https://www.aafp.org/practice-management/payment/coding/evaluation-management.html

https://www.aafp.org/practice-management/payment/coding/evaluation-management.html

https://www.aafp.org/practice-management/payment/coding/coding-basics.html

https://www.aafp.org/practice-management/payment/coding/coding-basics.html

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88. CMS CfMMS. Place of Service Code Set. Medicare: Place of Service Codes 2016; https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html. Accessed Feb 7, 2019, 2019.

89. DHHS USDoHaHS, CMS CfMMS. Revised and Clarified Place of Service (POS) Coding Instructions. In: Services USDoHaHSCfMM, ed. Vol MLN Matters® Number: MM7631; Related Change Request (CR) #: 7631; Related CR Release Date: March 29, 2013, Effective Date: April 1, 2013. Related CR Transmittal #:R2679CP; Implementation Date: April 1, 2013. Revised on April 28, 2016. http://www.cms.gov/ Centers for Medicare & Medicaid Services; Medicare Learning Network; 2016:1-9.

90. WHO WHO. International Classificaiton of Diseases (ICD). Classifications 2014; https://web.archive.org/web/20140212190115/http://www.who.int/classifications/icd/en/. Accessed Feb 7, 2019, 2019.

91. Cartwright DJ. ICD-9-CM to ICD-10-CM Codes: What? Why? How? Advances in wound care. 2013;2(10):588-592.

92. Menchaca V. Coding, Billing, and Reimbursement Essentials for the Clinical Scribe. In: Bray B, ed. ScribeConnect Clinical Scribe ACCELERATOR Training (CSAT) Platform. Unpublished2019.

93. CDC CfDCaP, NCHS NCfHS. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). National Center for Health Statitsitcs: Classification of Diseases, Functioning, and Disability 2018; https://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed Feb 7, 2019, 2019.

94. Heidelbaugh JJ, Riley M, Habetler JM. 10 billing & coding tips to boost your reimbursement. The Journal of family practice. 2008;57(11):724-730.

95. USF UoSF. Documentation of Evaluation & Management Services. Section 5 - Documentation, Coding, and Billing of Healthcare Services, Revised April 2000. In USF COM Standards of Conduct & Policies.: University of Southern Florida; 2000.

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Chapter 17. Two-Fold Legality

Chapter 18. Legal Regulations

Chapter 19. The Legal Medical Record

Chapter 20. Medicolegal Documentation (I): Audits & Amendments

Chapter 21. Medicolegal Documentation (II): The Expanded SOOOAAP Note

Chapter 22. Malpractice Prevention

Module IV:Medico-Legal Documentation

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Chapter 17: Two-Fold Legality ..................................................................................................445

Two-Fold Legal Aspects of Medical Documentation ................................................................ 446Suggested Review ................................................................................................................................ 446Module IV Overview ............................................................................................................................ 446General Review ...................................................................................................................................... 447

Chapter 18: Legal Regulations .................................................................................................448

Legal Aspects of Regulatory Compliance ..................................................................................... 449Recommended Resources .................................................................................................................. 449Review ...................................................................................................................................................... 450Assessment #1 (19 Questions) ........................................................................................................ 455Final Assessment (16 Questions) .................................................................................................... 461

Chapter 19: The Legal Medical Record ....................................................................................464

The Legal Medical Record ................................................................................................................. 465Recommended Resources .................................................................................................................. 465Review ...................................................................................................................................................... 467Assessment (16 Questions) ............................................................................................................... 468

Chapter 20: Medicolegal Documentation (I): Audits & Amendments .................................473

The Legal Medical Record ................................................................................................................. 474Recommended Resources .................................................................................................................. 474Review ...................................................................................................................................................... 477Assessment #1 (22 Questions) ........................................................................................................ 478Final Assessment (21 Questions) .................................................................................................... 485

Chapter 21: Medicolegal Documentation (II): The Expanded SOOOAAP Note ...................489

Medico-Legal Documentation II: The Expanded SOOOAAP Note ....................................... 490Recommended Resources .................................................................................................................. 490Review ...................................................................................................................................................... 491Assessment #1 (18 Questions) ........................................................................................................ 491Final Assessment (13 Questions) .................................................................................................... 502

Chapter 22: Malpractice Prevention ........................................................................................504

Malpractice Prevention....................................................................................................................... 505Recommended Resources .................................................................................................................. 505Review ..................................................................................................................................................... 507Assessment # 1 (19 Questions) ....................................................................................................... 507Final Assessment (15 Questions) .................................................................................................... 515

References Module IV: ...............................................................................................................517

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Chapter 17 Suggested Review

1. CSAT Module I: General & Regulatory Aspects of Medical Documentation

h Chapter 5: Industry Regulations (HIPAA & HITECH)

2. CSAT Module III: Financial Aspects of Medical Documentation

h Chapter 12: Historical Overview of the Healthcare Industry

h Chapter 13: MACRA & QPP

h Chapter 15: E/M Coding in Depth

Chapter 17 Module IV Overview

Once you have reviewed the suggested chapters in Modules I and III, we invite you to commence with this module!

h Chapter 18 – Legal Regulations:

• Important aspects of HIPAA & HITECH policy are reviewed

h Chapter 19 – The Legal Medical Record (LMR):

• The Legal Medical Record (LMR) is introduced and distinguished from the clinical medical record (CMR), and from the Designated Record Set (DRS)

h Chapter 20 – Medicolegal Documentation I:

• Audit Logs

• Documentation Amendments

Two-Fold Legal Aspects of Medical Documentation

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h Chapter 21 – Medicolegal Documentation II:

• SOOOAAP note documentation is reviewed as the medicolegal documentation standard for preventing malpractice

h Chapter 22 – Malpractice Prevention Tips:

• Best Practices in Medical Documentation are provided in light of a variety of literature on medical malpractice documentation claims

Chapter 17 General Review

Chapter 1 of this course identifies the 4 Pillars of Medical Documentation, which include:

h General Aspects

h Medical Aspects

h Financial Aspects

h Legal Aspects

The legal aspects of medical documentation that pertain to clinical scribes are two-fold, involving:

h Legal Regulations:

• Legal obligations to comply with HIPAA & HITECH Standards

• Legal obligations to comply with other standards that protect against fraudulent coding, billing, and reimbursement claims for medical services (such as E/M Service Documentation)

h The Medical Record as a Legal Document:

• Legal Medical Record (LMR), as distinct from the Clinical Medical Record (CMR)

These two legal aspects of the clinical scribe role are often intertwined. However, we addressed them individually in chapters 18 and 19.

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18Legal Regulations

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Define the following acronyms:

1. ePHI:

2. HIPAA:

3. HITECH:

4. PHI:

5. Individually identifiable health information includes (select all that apply):

a. Demographic information collected from an individual that identifies the individual

b. Demographic information collected from an individual with respect to which there is a reasonable basis to believe the information can be used to identify the individual

c. Photographic information collected from an individual that identifies the individual

d. Photographic information obtained form an individual

6. Excluding education and employment records, protected health information (PHI) includes (select all that apply):

a. Any information that is transmitted or maintained in any electronic form or medium

b. Individually identifiable health information that is maintained in electronic media

c. Individually identifiable health information that is transmitted by electronic media

d. Individually identifiable health information that is transmitted or maintained in any form or medium, except for exempt education and employment records

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1. What is Individually identifiable health information? Provide 3 examples of how you might interact with individually identifiable health information in your role as a clinical scribe.

2. What is protected health information? Provide 3 examples of how you might interact with PHI in your role as a clinical scribe.

3. What is the “Minimum Necessary” Rule? How does it apply to the way that you can- and cannot use PHI in your role as a clinical scribe?

4. What is an audit trail and how does it relate to your interaction with ePHI?

5. Who are the privacy personnel at the healthcare facility you work with/for? How can you access these individuals? Provide 3 examples of situations in which you may need to interact with your facility’s privacy personnel.

6. HIPAA’s Security Rule requires that you receive training-, management-, and enforcement on- and of the Privacy Policies developed by the administration staff at the healthcare organization your work for/with. How can you ensure that you receive HIPAA training? How will your HIPAA compliance be managed and enforced by the healthcare organization you work with?

7. According to HIPAA Privacy Rule’s Administrative Requirements, covered entities are required to develop and implement which of the following (select all that apply):

a. Written Privacy Policies and Procedures that are consistent with the Privacy Rule

b. A designated privacy official responsible for developing and implementing privacy policies and procedures.

c. A contact person or office responsible for receiving complaints and providing individuals with information on the covered entity’s privacy practices.

d. Training, Management, and Enforcement of privacy policies and procedures for all workforce personnel – including employees, volunteers, and trainees – which includes appropriation of sanctions against workforce members who violate the entity’s privacy policies and procedures or the Privacy Rule.

e. Data Safeguards to maintain “reasonable and appropriate administrative, technical, and physical safeguards [that] prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure.”

f. All of the above.

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19The Legal Medical Record

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h Business Record:

“A record prepared and kept in the regular course of business that can legally be received into evidence in court if the method of record keeping conforms to certain established guidelines:

• “The record was made in the regular course of business

• The entries in the record are made promptly

• The entries were made by the individual within the enterprise with first-hand knowledge of the acts, events, conditions, and opinions

• Process control and checks exist to ensure the reliability and accuracy of the record

• Policies and procedures exist to protect the record from alteration and tampering

• Policies and procedures exist to prevent loss of stored data6.”

h Legal Health Record:

Medical record that is “generated at or for a healthcare organization as its business record and is the record that would be released upon request6.”


1. The three main purposes of a patient’s medical record are to provide (select all that apply):

a. Regulatory documentation, including proof of HIPAA and HITECH compliance

b. Medical documentation regarding patient care

c. Financial documentation used for coding, billing, and reimbursement

d. Legal documentation

2. Medical Records can provide ____________documentation. Select all that apply.

a. Patient Care

b. Public Health

c. Financial/Business

d. Legal

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Chapter 20: Medicolegal Documentation - (I): Audits & Amendments

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20Medicolegal Documentation (I): Audits & Amendments

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ii. Avoid pre-populating templates

iii. Avoid cut-and-paste/copy forward

iv. Be cautious when amending documentation

h https://www.mnmed.org/MMA/media/Minnesota-Medicine-Magazine/MEDLAW_LUGTU_1503.pdf

6. Sheber S. New Toolkit Provides Guidelines for EHR Amendments. Journal of AHIMA / American Health Information Management Association. 2012.

h This one-page article reviews the American Health Information Management Assocation (AHIMA)’s 2012 toolkit “Amendments in the Electronic Health Record,” which provides guidance on how to maintain the integrity and accuracy of an electronic medical record when using an EHR system’s amendment functionality.

h The article reviews guidelines on:

i. Addendums

ii. Corrections

iii. Late Entries

iv. Retractions

v. Delections

vi. Re-sequencing or Reassignment

h https://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/

Chapter 20 Review

1. Because medical records can be used in a court of law, all interactions with patient health information should be conducted as interactions with legal evidence. Creating, altering, and/or deleting medical health records or patient health information has the potential to constitute tampering with- and/or destroying legal evidence, and should be viewed as such by all clinical scribes.

2. Regulatory standards require that all attempts to access ePHI and all interactions with ePHI be recorded, retained, and periodically reviewed by designated administrative personnel.

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3. All healthcare organizations are required to employ policies and procedures for amending medical health records7.. These policies and procedures should pertain specifically to the following types of amendments:

h Addendums

h Corrections

h Retractions

h Deletions

h Late Entries

h Re-sequencing or Reassignment

4. As a clinical scribe, you are not qualified to instruct your provider on how to care for his or her patients. However, by remaining of aware of “best practices” in medical documentation for preventing legal malpractice, you can ensure that you accurately document all “best practice” measures that your provider engages in.


For Questions 1 – 6: Refer to Michelle Dougherty, RHI, CHP’s article “How Legal Is Your EHR?: Identifying Key Functions That Support a Legal record (Journal of AHIMA, 2008: http://bok.ahima.org/doc?oid=77552#.XSkWV5NKjUq).

1. What are three Security Functions identified in the article that apply to your role as a Clinical Scribe?

2. What are three Health Record Information & Management Functions identified by HL7’s RM-ES Functional Profile?

3. What are the two Business Rules & Workflow Management Functions identified by HL7’s RM-ES Functional Profile?

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21. Which of the following actions refers to “the process of moving one or more documents from one episode of care to another within the same patient record, for example, the history and physical posted to the incorrect episode?”

a. Addendum

b. Correction

c. Late Entry

d. Retraction

e. Deletion

f. Reassignment

g. Resequencing

22. You realize during your shift that you have entered Patient A’s HPI into Patient B’s medical record, and vice versa. Patient A was a patient you saw at the beginning of the shift, and your provider has already signed this patient’s note. What should you do?


For questions 1 – 5: Define the following terms and describe how they apply to your role as a clinical scribe:

1. Audit Trail:

2. Data Retention:

3. Data Availability:

4. Data Destruction:

5. Record Preservation:

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For Questions 11 – 13: Refer to Trish Lugtu’s article “Toward safer EHR use and documentation. Tips for reducing malpractice risk” (2015: https://www.mnmed.org/MMA/media/Minnesota-Medicine-Magazine/MEDLAW_LUGTU_1503.pdf)

12. What are the five types of documentation amendments addressed in the article?

13. What four suggestions are recommended in the article for reducing malpractice risk in electronic medical record documentation?

14. Lugtu defines _____________ as “a range of alterations that are intended to clarify information.”

For Questions 15 – 21: Refer to AHIMA’s 2012 toolkit , which is reviewed in Sheber’s 2012 article “New Toolkit Provides Guidelines for EHR Amendments. (J. AHIMA, 2012: https://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/).

15. What seven EHR amendment types are reviewed in AHIMA’s 2012 toolkit and reviewed in Sheber’s 2012 article “New Toolkit Provides Guidelines for EHR Amendments. (J. AHIMA, 2012: https://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/)?

16. According to AHIMA, what is the only appropriate way to correct or revise a medical document once the document has a final sign-off?

17. According to AHIMA, what two requirements must all addendums meet?

18. Which of the following actions completely eliminate information from an EHR and are highly discouraged, as they entail high legal risk?

i. Addendum

ii. Correction

iii. Late Entry

iv. Retraction

v. Deletion

vi. Reassignment

vii. Resequencing

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Chapter 21: Medicolegal Documentation - (II): The Expanded SOOOAAP Note

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21Medicolegal Documentation (I): Audits & Amendments

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3. Teichman, P. Documentation Tips for Reducing Malpractice. Family Practice Management. 2000; 7(3):29-3343.

h https://www.aafp.org/fpm/2000/0300/p29.html

h Introduces Expanded SOOOAAP Note Format for Medico-Legal Documentation

h Peter Teichman, MD, MPA

Medico-Legal Documentation II:The Expanded SOOOAAP Note

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Chapter 21 Review

1. The SOOOAAP Note method of documentation has been prorposed to minimize legal risk associated with medical documentation and includes the following sections8:

h Subjective Information

h Objective Information

h Medical Opinion

h Options Discussed with the Patient

h Medical Advice

h Agreed-Upon Plan

2. As a clinical scribe, you are not qualified to instruct your provider on how to care for his or her patients. However, by remaining of aware of “best practices” in medical documentation for preventing legal malpractice, you can ensure that you accurately document all “best practice” measures that your provider engages in.


The questions in this quiz refer to Dr. Peter Teichman’s 2007 article: “Documentation Tips for Reducing Malpractice.”

h Available online at: https://www.aafp.org/fpm/2000/0300/p29.html

h Full citation: Teichman PG. Documentation tips for reducing malpractice risk. Family practice management. 2000;7(3):29-33.

1. What does the SOOOAAP acronym stand for in Dr. Teichman’s article?

2. Which of the following sections of a medical record are included in the “Subjective” part of the SOOOAAP Note? Select all that apply

a. Chief Complaint

b. History of Present Illness (HPI)

c. Past, Family, Social History (PMFSH)

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The questions in this quiz refer to Dr. Peter Teichman’s 2007 article: “Documentation Tips for Reducing Malpractice.”

h Available online at: https://www.aafp.org/fpm/2000/0300/p29.html

h Full citation: Teichman PG. Documentation tips for reducing malpractice risk. Family practice management. 2000;7(3):29-33.

1. What does the SOOOAAP acronym stand for in Dr. Teichman’s article?

2. Which sections of a medical record are included in the “Subjective” part of the SOOOAAP Note?

3. Which sections of a medical record are included in the “Objective” part of the SOOOAAP Note? Select all that apply

4. Which sections of a medical record or aspects of the patient-provider encounter are included in the “Medical Opinion” part of the SOOOAAP Note?

5. Which sections of a medical record or aspects of the patient-provider encounter are included in the “Options discussed with the patient” part of the SOOOAAP Note?

6. Which sections of a medical record or aspects of the patient-provider encounter are included in the “Medical Advice” part of the SOOOAAP Note?

7. Which sections of a medical record or aspects of the patient-provider encounter are included in the “Agreed-Upon Plan” part of the SOOOAAP Note?

8. What seven suggestions does Teichman provide for documenting in the “Objective” portion of a patient’s SOOOAAP medical record?

9. What four phrases and discussions does Teichman suggest documenting in the “Subjective” and “Objective” portions of a SOOOAAP Note when they occur?

10. What are five phrases and discussions Teichman suggests documenting in the “Opinion” and “Options” sections of a SOOOAAP Note when the occur?

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Chapter 22: Malpractice Prevention

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22Malpractice Prevention

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3. Ruder DB. Malpractice Claims Analysis Confirms Risks in EHRs. Journal of medical practice management. 2010;26(1):21-2454

h https://www.psqh.com/analysis/malpractice-claims-analysis-confirms-risks-in-ehrs/

h Overviews CRICO’s claims information database.

h CRICO is a patient safety and medical malpractice insurer that “provides claims management, litigation, and education services to its member owners54.” CRICO member owners include > 12,000 physicians, 22 hospitals, and 100,000 nurses, technicians, and other employees of Harvard-affiliated organizations54.

Malpractice Prevention

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Chapter 22 Review

1. The False Claims Act is a federal law that prohibits any person from knowingly submitting a false claim for payment to the U.S. government. This includes any claim for services rendered to a Medicare or Medicaid beneficiary that is false or contains services that are not deemed medically necessary.

2. The following documentation practices will help to minimize legal risk with regard to medical documentation:

h Remembering the mantra: “If an action is not documented it has not occurred.”

h Document with accuracy: check and re-check.

h Avoid unnecessary detail.

h Document precisely.

h Document objectively.

h Document with meticulous grammatical accuracy.

h Document in a timely fashion, and record timing of events.

h Document consistently.

Chapter 22 Assessment # 1 (19 Questions)

1. Which of the following statements are true of the False Claims Act? Select all that apply.

a. The False Claims Act is a federal law that prohibits any person from knowingly submitting any false claim for payment to the U.S. government.

b. The False Claims Act applies to any medical claim for goods or services that are either not medically necessary or did not occur.

c. Under the False Claims Act, any good or service that is not medically necessary or did not occur cannot be submitted for reimbursement or payment to the U.S. government.

d. Under the False Claims Act, oding for services rendered to a patient at a higher code than medically necessary constitutes fraud and is penalized in accordance with the False Claims.

e. All of the above statements are true.

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1. What is the False Claims Act?

2. What is Medical Necessity?

3. What are the eight SuperScribe Tips Provided in this chapter to help reduced legal risk in medical documentation?

4. Fill in the blank: Malpractice lawsuits most commonly succeed because of _________ medical documentation. (Four answers are correct).

5. The medical record should clearly narrate the provider’s thought process regarding what ten components of the encounter?

6. True or False: If a piece of information is not included in the medical record, one may legally assume that piece of information was not documented because it was not obtained or did not occur.

7. Complete the sentence: Proper medico-legal documentation must convey that a service was (four correct responses apply):

8. Which of the following examples are highlighted in this chaper as the acceptable option for objective documentation?

a. “The patient is mentally ill and rambling names of Star Trek characters.”

b. “The patient presents alert, but referencing Star Trek characters throughout the history.”

9. Which of the following examples are highlighted in this chaper as the acceptable option for objective documentation?

a. “The patient presents with R eye hematoma, various contusions to bilateral wrists.”

b. “The patient presents with black eye and wrist bruises from domestic abuse.”

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Module IV References:

1. OCR OoCR. OCR Summary of the HIPAA Privacy Rule. In: RIghts USDoHaHSOoC, ed. http://www.hhs.gov/ U.S. Department of Health and Human Services; 2003:23.

2. OCR OoCR. Summary of the HIPAA Privacy Rule. 2013; https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html?language=en. Accessed Jan 23, 2019, 2019.

3. DHHS USDoHaHS. Security Standards: Administrative Safeguards. In: U.S. Department of Labor WaHD, ed. Vol 2. http://www.hhs.gov/ U.S. Department of Health and Human Services; 2007.


5. DHHS USDoHaHS. 45 CFR 164.501 - Definitions. In: Services USDoHaH, ed. Vol Title 45 Code of Federal Regulations, Subtitle A, Subchapter C, Part 164, Subart E, Section 164.501. http://www.govinfo.gov/ Government Publishing Office; 2004.

6. Bartschat W, Blevins A, Burnette L, et al. The legal process and electronic health records. Journal of AHIMA / American Health Information Management Association. 2005;76(9):96a-96d.

7. Medical Records: Documentation of Patient Care in the Legal Healht Record: From a Risk Management Perspective. Practice Tips Online Library https://www.medicalmutual.com/risk/practice-tips/tip/medical-records-documentation-of-patient-care-in-the-legal-health-record/74. Accessed Feb 18, 2019, 2019.

8. Teichman PG. Documentation tips for reducing malpractice risk. Family practice management. 2000;7(3):29-33.

9. Davenport J. Documenting High-Risk Cases to Avoid Malpractice Liability. Family practice management. 2000;7(9):33-36.

Module IV References

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http://www.cms.gov/

http://www.govinfo.gov/

https://www.medicalmutual.com/risk/practice-tips/tip/medical-records-documentation-of-patient-care-i



Scribe Integration Resources

Provider Preference Documents

Family Medicine Documentation Basics

Documentation Basics for Common Chief Complaints in Family Medicine

Documentation Basics for Preventive Measures in Family Medicine

E/M Level Coding Chart

Hierarchical Condition Category Coding and Risk Adjustment Factors (HCC & RAFs)

HIPAA & HITECH – In Greater Depth

Medical Terminology

Medical Abbreviations

Scribe Documentation Tips for Meeting Regulatory Standards (NPS, MIPS, & TJC)

Assessment Answer Key

Appendices

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A.1

Appendix - Table of Contents – In Detail

Appendix A.I

Scribe Integration Resources ............................................................................................................ A.I.2

Appendix A.II

Provider Preference Documents .................................................................................................... A.II. 6

Appendix A.III

Family Medicine Documentation Basics ................................................................................. A.III. 20

Appendix A.IV

Documentation Basics for Common Chief Complaints in Family Medicine .................A.IV.28

Appendix A.V

Documentation Basics forPreventive Measures in Family Medicine ............................... A.V.41

Appendix A.VI

E/M Level Coding Chart ................................................................................................................. A.VI.48

Appendix A.VII

Hierarchical Condition Category Coding and Risk Adjustment Factors (HCC & RAFs) ......... A.VII.50

Appendix A.VIII

HIPAA & HITECH – In Greater Depth ......................................................................................A.VIII.51

Appendix A.IX

Medical Terminology ......................................................................................................................A.IX.52

Appendix A.X

Medical Abbreviations .................................................................................................................... A.X.67

Appendix A.XI

Scribe Documentation Tips for Meeting Regulatory Standards (NPS, MIPS, & TJC) .........A.XI.77

Appendix A.XII

Assessment Answer Key ...............................................................................................................A.XII.81

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Scribe Integration Resources

Appendi A I

A A.I I A A . A A . .

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A.I.4

Appendix A.I: Scribe Integration Resources

. . A

Perspectives® Newsletter: The Official Newsletter of The Joint ommission. 2018 8 8 1.

2018 A 1

A . .. A I 180

. I . A . Joint ommission ournal on ualit

an atient safet / Joint ommission esources. 2018 44 5 2 8 24 .

.

. 2018 .

.

.. 155 7250 17 04 2 4

. A . . J en Intern Me . 2016 1 0

5.

1

6 .

. . . .4 78677 11606 2016 A 71 .

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Provider Preference Documents

Appendix A.II

See “Appendix A.II Provider Preference Documents” under the Resources Tab of the ScribeACCELERATOR website (www.scribeACCELERATOR.com).

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Appendix A.II: ro i er re erence ocu ents

Treatment Plans By Body Systems

Chronic Diagnoses

DM II

. I . A .

HTN - use template ( BPControlled)

. I . A .

Mixed hyperlipidemia/ High cholesterol/ Hyperlipidemia

A . 0 .

Vitamin D

V . V . .

V 1000 I .

Chronic Pain

Controlled ncontrolled on medication . efill narcotic . Continue current Stop Start med .

Preop Exam/ ther EKG related Dx

done in office, negati e findings noted.

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A.II.11

Appendix A.II: ro i er re erence ocu ents

Skin

Acne

. .

. . A . .

. . infections and scarring. oid touching her face with her hands or fingers. Do not lea e makeup

.

Dermatitis

A . A . A . 11

.

Ec ema

Try not to scratch the rash or your skin in the inflamed area. ntihistamines taken by mouth may . . 2 .

scents, dyes. a ing humidifier in the home may also help. oisturi ers work best when they are . A .

. . .

Ears, Nose, & Throat (ENT) and pper Respiratory Infections ( RIs)

Nose Bleeds

thumb and finger for full minutes. ean forward to a oid swelling the blood and breathing

. 10 . I

. . 20 .

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Appendix A.III: a i e icine ocu entation asics

Family Medicine Documentation Basics

Appendi A III

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Documentation

► I . nsurance, pt’s insurances are listed. Select edicare, then see when pt was first

.

► I . A A I . .

A I

A I A

► . I . I

► . .

A A A A

65 A A . A A A A . I

note mm dd yy in the yellow sticky. should be the first thing listed in the sticky.

A A A A

A A.

I A A AHA ( pdated).

I A A .

Be sure to update fill out these sections appropriately, as it is required for to be .

► Social This section ST be filled out. f the patient did not fill this out in the .

► Delete the and fill out the

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► A

► I .

.

► I . I

. . A1 .

► .

A A

► A A A 7 10

A A

► f a patient is here for an ffice isit, on the left hand column, under “ Ser ices”

select “ st atient” then select or based on length of office isit, if unsure, confirm with pro ider

. 20 based on length of office isit, if unsure, confirm with pro ider

► I X

.

I .

I 2 . ffice isit Code and another is a modifier.

Select “ odifiers”, and select Separate

X, , and codes A I .

00.00

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► F/u Hospital Admission (within days)

► F/u Hospital Admission ( - days after)

. I

. I I .

edical istory erification

.

A .

.

.

A . . I

. I .

► MEDICARE ELLNESS months

► MEDICARE ELLNESS - months

► MEDICARE ELLNESS - months

ake sure that the patient recei ed edicare xam paperwork or confirm with the front desk that it was gi en then fill out the paperwork appropriately.

►

►

► A

►

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.

► V

► is fulfilling their core measure.

60 74 1 AAA .

X .

► Screening AAA S- former smoker

► Screening AAA S- current smoker

► Screening for AAA X

I I 25 .

I A I V

I 25 2 I 28

I 0 .

I 0 4.

I 5 5.

I 40

► eight management

► eight MGMT verweight

► eight MGMT BMI -

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A.IV.28

Appendix A.IV: Documentation Basics for Common Chief Complaints in Family Medicine

Documentation Basics for Common Chief Complaints in Family Medicine

Appendi A I

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A.IV.2

Appendix A.IV: Documentation Basics for Common Chief Complaints in Family Medicine

Common Chief Complaints Basic Info

A

.

► . . . .

► .

► A

► I

►

► A I A A I A XI IA . I

A

I . facilities confirm whether this is the case for your facility. Confirm with pro ider if they

.

A 1

A 11

► I A A I I I A A I

► I I A I I A

► I A

► I I

►

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A.V.41

Appendix A. : ocu entation asics or re enti e easures in a i e icine

Documentation Basics for Preventive Measures in Family Medicine

Appendi A

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A.V.42


Preventative Measures

A I . .

mm dd yy mammogram ordered mm dd yy flu influen a mm dd yy

A A

.

. . . I A A 2012 A . I

A .

I

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► 5 .20

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► 28.21

► 28.

50 .

I 10 . I

5 .

.

I .

I I A I I A .

. A I .

► A I I I

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► IA

► A

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65 70.

A XA . I XA 2

A .

.

40 . .

. .

.

► ELL MAN (PAP EST routine labs, Px)

► ELL MAN EXAM (Pap Px, no routine labs)

► E nly (Pap, no Px, no routine labs)

A . .

► A A A

► A

A . A A .

A .

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A.VI.48

Appendix A. I: e e o ing art

E/M Level Coding Chart

Appendi A I

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A.VII.50

Appendix A. II: ierarc ica on ition ategor o ing an Ris ust ent actors R s

Hierarchical Condition Category Coding and Risk Adjustment Factors (HCC & RAFs)

Appendi A II

A A.VII A A A A . A A .

.

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Appendix A. III: I I In reater e t

HIPAA & HITECH – In Greater Depth

Appendi A III

A A.VIII I AA I I A A . A A .

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A.IX.52

Appendix A.I : e ica er ino og

Medical Terminology

Appendi A I

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Appendix A.I : e ica er ino og

eflexes ormal reflexes rated on a scale of where is normal

5 5

- A -

A A

bdominal ortic neurysm bnormal blood filled dilatation of the abdominal

A

A

A

A

A

A

mbulatory ble to mo e about, not confined to a bed

A A A

nemia Condition in which blood is deficient in BC, B, or total olume

A

A A

A

A

scites bnormal accumulation of serious fluid in the abdominal ca ity, in spaces

A

A A A

A

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A.X.67

Appendix A. : e ica bbre iations

Medical Abbreviations

Appendi A

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A.X.68

Appendix A. : e ica bbre iations

- A -

A A

AAA A A A

A A

A A

A X A

A A

A A

A A

A A A A

A I A I

A A

. A

A

A A A A A

- B -

- C -

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A.XI.77

Appendix A.IV: Scribe Documentation Tips for Meeting Regulatory Standards (NPS, MIPS, & TJC)

Appendi A I

Scribe Documentation Tips for Meeting Regulatory Standards (NPS, MIPS, & TJC)

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A.XI.78


D C MENTI N TIPS F R MEETING REG LAT R STANDARDS

NATI NAL PATIENT SAFET G ALS

. Universal Procedure Protocol: atient identity, procedure type, and location erified. Time out conducted with all team members in ol ed to confirm at a minimum correct patient identity

. .

isks and Benefits of the procedure often discussed with patient and documented as .

. Blood Transfusion: atient is correctly identified blood type is correctly identified prior to transfusion. dentification erification is documented.

. Identify Patient Safety Risks: .

. Medicine Use Safety: . A .

.

. Prevent Infection: . .

. 24-hr Documentation: In accordance with TJC Standards, each patient must have a History and Physical (H&P) performed and documented within 24 hours of admission as an inpatient.

MIPS PR M TING INTER PERABILIT MEAS RES (F RMERL MEANINGF L SE)

. ecord specific demographics

. changes in vital signs

. smoking status 1

. I clinical lab-test

. se clinically rele ant information from technology to identify patient specific educational resources

. I

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. electronic notes

. family health history

MIPS ALIT CARE & IMPR EMENT ACTI ITIES MEAS RES (F RMERL P RS MEAS RES)

. Aspirin Acute Myocardial Infarction A I

. Emergency Medicine -Lead ECG Performed for Non-Traumatic Chest Pain

. -Lead ECG Syncope

. A (A E) Topical Therapy

. A A Suicide Risk Assessment

. Pain Assessment and Follow- p

. Falls Risk Assessment

. Tobacco se Screening and Cessation Intervention

. Substance se Counseling Treatment ptions A

TJC C RE MEAS RES

. cute Myocardial Infarction:

A A A

A

. Pneumonia Care:

24 I 24

. Children s sthma Care:

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Workbook: Answer Key

Appendix A.XII

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A.XII. 82

1. What are the “Four Pillars” of clinical documentation?

a. General

b. Medical

c. Financial (including billing, coding, and reimbursement)

d. Legal

2. 5 minimum core competencies suggested by the Joint Commission?

h Medical Terminology

h The Health Insurance Portability and Accountability Act (HIPAA)

h Principles of billing, coding, and reimbursement

h Electronic Medical Record (EMR) navigation and functionality

h Computerized order entry, clinical decision support, and proper methods for pending orders for authentication and submission

3. The four different phases of Clinical Scribe Training are:

h PHASE I: Classroom Training: 20 hours of classroom training that focus on conveying Subject Knowledge that is fundamental to the scribe role (the general, medical, financial, and legal aspects of clinical documentation), and highlights the importance of critical thinking skills.

h PHASE II: EHR-Specific Training: 16 – 24 hours of training on how to use your facility’s Electronic Health Record (EHR) system for documentation.

h PHASE III: Workflow Training: Up to 5 shifts of one-on-one “real time” training with an experienced Clinical Scribe or Scribe Trainer in the clinical setting. This provides new Clinical Scribes with an opportunity to observe, model, and receive real-time instruction and feedback from experienced Clinical Scribes while applying content and concepts covered in STAGES I and II to the clinical environment.

Chapter 1 – Assessment Answer Key (8 Questions)

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A.XII. 83

h PHASE IV: 90-Day Evaluation Period): “Probationary” evaluation phase that uses regulated assessment tools to monitor each Clinical Scribe’s continued progress toward independent performance objectives.

h This textbook assists in PHASE I: Classroom Training.

4. ScribeConnect’s “SC Smarts” stand for S: Subject Knowledge: Primary information that is fundamental to the scribe role, including the general, medical, financial, and legal aspects of clinical documentation. C: Critical Thinking Skills.

5. Medical decision making describes the methodical step-wise process by which physicians use subjective and objective information made available to them during the patient encounter to identify a list of all possible diagnoses or problems that could be contributing to a patient’s chief complaint(s) or illness(es) and subsequently to identify the most likely cause(s) or diagnoses (termed the “definitive diagnosis/diagnoses”).

h Chapter 6 in Module II describes medical decision making more succinctly as the process by which “differential diagnoses are ruled-in and ruled-out to arrive at a definitive diagnosis.”

h Like medical decision-making, critical thinking is described in this chapter and in academic literature as a methodical step-wise process that includes components of assessment, communication, and problem-solving that utilizes the scientific method.

h The SuperScribe Tip Box on “Critical Thinking in Critical Practice” in chapter 1 notes that the assessment, communication, and problem-solving skills that are central to critical thinking closely parallel the provider’s medical decision-making process, in which:

9 Problems and questions are clearly identified and articulated.

9 Subjective and Objective information are obtained, synthesized, and assessed.

9 Information is communicated with others (ex: the patient and specialists).

9 Problems are methodically solved by:

1. Identifying all possible causes for each problem.

2. Methodically conducting studies to accept or reject each possible cause.

3. Selecting the most likely cause and Implementing a Solution.

4. Identifying measurable outcomes to assess the solution’s efficacy.

5. Identifying a specific reassessment plan.

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Appendix: Answer Key References

A.XII. 225

1. Commission TJ. Documentation Assistance Provided by Scribes: What guidelines should be followed when physicians or other licensed independent practitioners use scribes to assist with documentation? Perspectives® Newsletter: The Official Newsletter of The Joint Commission. 2018;38(8).

2. ScribeConnect L, Inventor. ScribeConnect, LLC.

3. Edemekong PF, Haydel MJ. Health Insurance Portability and Accountability Act (HIPAA). In: StatPearls. Treasure Island (FL): StatPearls Publishing LLC.; 2018.

4. OCR OoCR. Summary of the HIPAA Privacy Rule. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html?language=en. Published 2013. Updated July 26, 2013. Accessed Jan 23, 2019, 2019.

5. DHHS USDoHaHS. Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules In: Services USDoHaH, ed. Vol 78. Fedderal Register: Federal Register; 2013:5566-5702.

6. OCR OoCR. Minimum Necessary Requirement. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/minimum-necessary-requirement/index.html. Published 2013. Updated July 26, 2013. Accessed Jan 24, 2019, 2019.

7. OCR OoCR. Minimum Necessary. In: Services USDoHaH, ed. Vol [45 CFR 164.502(b), 164.514(d)] www.hhs.gov: U.S. Department of Health and Human Services; 2003.

8. DHHS USDoHaHS. Security Standards: Administrative Safeguards. In: U.S. Department of Labor WaHD, ed. Vol 2. www.hhs.gov: U.S. Department of Health and Human Services; 2007.

9. OCR OoCR. HIPAA for Professionals. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/index.html. Published 2019. Updated June 16, 2017. Accessed Jan 23, 2019, 2019.

Answer Key References:

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https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/minimum-necessary-requirement/index.htm

http://www.hhs.gov

http://www.hhs.gov

https://www.hhs.gov/hipaa/for-professionals/index.html

Appendix: Answer Key References

A.XII. 228

30. CMS CfMMS, DHHS USDoHaHS. CMS Manual. In: Centers for Medicare & Medicaid Services (CMS) USDoHaHS, ed. Vol Pub 100-03 Medicare National Coverage Determinations. Transmittal 202. Change Requrest 10199. www.cms.gov: Centers for Medicare & Medicaid Services (CMS); U.S. Department of Health and Human Services (DHHS); 2017.

31. AAFP AAoFP. Hierarchical Condition Category Coding. American Academy of Family Physicians. Practice Management: Medical Billing and Coding Web site. https://www.aafp.org/practice-management/payment/coding/hcc.html. Accessed Jan 28, 2019, 2019.

32. DHHS USDoHaHS. 45 CFR 160.103 - Definitions. In: DHHS USDoHaHS, ed. Vol Title 45, Vol 1. www.govinfo.gov: Government Publishing Office.

33. DHHS USDoHaHS. 45 CFR § 164.502 Uses and disclosures of protected health information: general rules. In: Services USDoHaH, ed. Vol Title 45. Chapter A. Subhcapter C. www.govinfo.gov: Government Publishing Office.

34. Abernathy DG, Kim WK, McCoy MJ, et al. MicroRNAs Induce a Permissive Chromatin Environment that Enables Neuronal Subtype-Specific Reprogramming of Adult Human Fibroblasts. Cell stem cell. 2017;21(3):332-348.e339.

35. Lugtu T. Toward safer EHR use and documentation. Tips for reducing malpractice risk. Minnesota medicine. 2015;98(3):36-37.

36. Sheber S. New Toolkit Provides Guidelines for EHR Amendments. Journal of AHIMA / American Health Information Management Association. 2012. https://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/. Published Aug 29, 2019. Accessed Feb 15, 2019.

37. Teichman PG. Documentation tips for reducing malpractice risk. Family practice management. 2000;7(3):29-33.

38. Davenport J. Documenting High-Risk Cases to Avoid Malpractice Liability. Family practice management. 2000;7(9):33-36.

39. CRICO Challenges EMR Complacency [press release]. Cambridge, MA; www.rmf.harvard.edu: CRICO, Feb 6, 2013 2013.

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http://www.cms.gov

http://www.govinfo.gov





http://www.rmf.harvard.edu

http://www.rmf.harvard.edu