Clinical Documentation & Records Flashcards
7 cards from real CHS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Documentation & Records flashcards as text
Which of the following represents a HIPAA violation in a hyperbaric facility?
Answer: Leaving a patient's treatment log visible on an unattended front desk counter
Leaving patient records visible to unauthorized individuals at an unattended desk violates HIPAA's minimum necessary and safeguard standards.
A referring physician requests a copy of the hyperbaric treatment summary. What is required before release?
Answer: A valid patient authorization or a treatment relationship that falls under TPO
Records may be released to a treating physician under HIPAA's TPO (Treatment, Payment, Operations) exception or with a valid patient authorization.
In hyperbaric treatment documentation, 'FiO2' refers to:
Answer: Fraction of inspired oxygen
FiO2 (fraction of inspired oxygen) is documented to indicate the concentration of oxygen the patient breathes during treatment.
Which of the following is a required element in a hyperbaric pre-treatment assessment note?
Answer: Current vital signs and any change in medical status since last treatment
Pre-treatment assessments must document current vital signs and interval medical changes to ensure the patient is safe to undergo pressurization.
When a patient experiences claustrophobia during HBO treatment, the incident report should include:
Answer: Description of the episode, patient's response, interventions used, and outcome
Incident reports for adverse events like claustrophobia must be comprehensive, detailing the episode, interventions, and outcome for quality improvement and risk management.
The 'treatment protocol' section of a hyperbaric record specifies:
Answer: The prescribed pressure (ATA), duration, number of sessions, and breathing gas
The treatment protocol documents the physician-ordered parameters including pressure, duration, breathing gas, and total sessions prescribed.
For Medicare reimbursement of HBO therapy, the medical record must document which of the following?
Answer: Medical necessity with the approved diagnosis, treatment response, and physician supervision
Medicare requires documented medical necessity, an approved indication, ongoing treatment response, and physician supervision for HBO reimbursement.